JBR 2011-4 by office

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WETTEREN 1

P 702083

Volume 94 Page 169-230 July-August

Bimonthly

–

2011

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)

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Subscribers’ information The JBR-BTR is published 6 times a year. Subscription of members of the Belgian Society of Radiology are included in membership dues and are handled by the Society. Non-members’ subscriptions are available from the ARSMB-KVBMG. The rate is valid to date and can be amended without notice according to fluctuation of printing and material costs. Annual subscriptions or single issue orders should be made promptly. The publishers cannot guarantee supply of back issues. Change of address must be notified 60 days in advance. RATES: Annual Belgium 150 € Other Countries 175 € All amounts are net and include postal and handling charges.

Single issue 38 € 44 €

You are kindly invited to address all your correspondence to Mrs A. Hirsch and execute all payments to ARSMBKVBMG (see below).

Instructies voor abonnees Het JBR-BTR geeft 6 nummers uit per jaar. Het tarief is vatbaar voor wijzigingen zonder voorafgaand bericht, in verhouding tot de evolutie van de papierprijzen en loonkosten in de grafische nijverheid. Het abonnement van de leden van de Koninklijke Vereniging voor Radiologie is begrepen in de bijdrage van het lidgeld. De abonnementen van niet-leden zijn te onderschrijven bij de KVBMG. Jaarabonnementen of bestellingen van losse nummers moet zo snel mogelijk gebeuren, de uitgever waarborgt de levering van de vorige nummers niet voor de abonnementen die te laat werden onderschreven. De adresveranderingen moeten 60 dagen te voren gemeld worden. TARIEF: Jaarlijks Belgie 175 € Andere landen 200 € Verzendingskosten zijn inbegrepen.

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JBR-BTR ♦ 94/4 ♦ 2011 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 REVIEW ARTICLE: Liver metastases. W. Schima, C. Koelblinger, G. Lesnik, A. Ba-Ssalamah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Imaging of bladder cancer: update on current approaches for diagnosis. B. Turkbey, E. Bengi Turkbey, G. Ravizzini, M. Karcaaltincaba . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Prognostic value of vascularity index for the diagnosis of autoimmune thyroid disease. I. Banaka, G. Kaltsas, St. Antoniou, G. Kanakis, A. Zilos, Ch. Baltas, D. Thomas . . . . . . . . . . . . . . . . . . . . . . . . . 185 CT-guided percutaneous drainage of lung abscesses: review of 40 cases. M. Kelogrigoris, P. Tsagouli, K. Stathopoulos, I. Tsagaridou, L. Thanos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Late presentation of ureteral injury following laparoscopic colorectal surgery. A.M. Priola, S.M. Priola, G. Volpicelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Testicular sarcoidosis. M. Eyselbergs, R. D’Hauwe, K. De Cuyper, M. Camerlinck, B. Van Acken, R. Oyen, F.M. Vanhoenacker . . . . . . 199 Imaging in index finger radial collateral ligament injury: attention to detail really pays… N.C. Chotai, S.C. Tham, G. Wansaicheong, A.A. Tandon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Abnormal left single pulmonary vein: case report of an anecdotal variant. M. Bersou, P. Mailleux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Unusual clinical manifestation of lymphangiomatosis. O. Prieur, N. Damry, C. Heijmans, C. Christophe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Stage III xanthogranulomatous pyelonephritis treated with antibiotherapy and percutaneous drainage. E. Tarkan, A. Akin, L. Hatice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Conservative surgery for left-sided isolated tubal torsion in pregnancy. A. ten Cate, S. Han, A.S. Vliegen, L. Lewi, J. Verhaeghe, F. Claus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Takotsubo cardiomyopathy or apical ballooning: a case report and a short literature study. T. De Beule, L. Ardies, M. De Booij, E. Janssens, P. Vanhoenacker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

IMAGES IN CLINICAL RADIOLOGY Solitary osteochondroma: spontaneous regression. F.C. Deprez, M. Beltran-Marin, J. Malghem, R. Menten, P. Clapuyt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Multicentric carpal-tarsal osteolysis. J. Peeters, F.M. Vanhoenacker, G. Mortier, P.M. Parizel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Ossification of the ligamentum flavum in the cervical spine. L. Dewachter, D. Violon, I. Crevits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Mondor’s disease of the breast. A.S. Celebi, A. Ozel, A. Bayram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Reversible splenic ischemia in inflammatory bowel disease. S. Van Nieuwenhove, L. Ghijselings, J. Pringot, P. Matthys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Hyperostotic meningioma mimicking skull osteoma. M. Eyselbergs, F.M. Vanhoenacker, D. Kools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222 Fast progressive memory loss in a 63-year-old man. K. De Smet, M. De Maeseneer, T. Yazdi Amir, J. De Mey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 A male infant presenting with acute urinary retention. L.J. De Cocker, A. Van Baelen, M. Smet, L. Breysem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 Oblique meniscomeniscal ligament: a potential pitfall in the diagnosis of knee injury. H. Claes, S. Pans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

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Abstract of papers for full membership at the Royal Belgian Society of Radiology . . . . . . . . . . . . . . . . . . . . . . . . 226 Detection and characterization of unruptured intracranial aneurysms: comparison of 3T MRA and DSA. B. Minne Added value of MDCT in the evaluation for coronary artery fistulas. T. Vanderhasselt, K. De Smet, P. Dewachter, K. Tanaka, D. Verdries, J. De Mey 3T MR arthrography of glenohumeral lesions. S. Doering, C. Boulet, M. De Maeseneer, N. Pouliart, J. De Mey, M. Shahabpour RBRS Annual Symposium – Programme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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News from the Museum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Classified service: University Hospital of Mont-Godinne recruits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Grants of the RBRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subscribers information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Advertising index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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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. ◆

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Editor: J. Pringot

Royal Belgian Society of Radiology: Http://www.rbrs.org

Managing Editor: P. Seynaeve

President: B. Desprechins Vice-presidents: J.F. De Wispelaere, R. Hermans

Editorial Board: B. Appel, F. Avni, P. Beeckman, L. Breysem,N. Buls, P. Clapuyt, B. Coulier, B. Daenen, E. Danse,H. Degryse, P. Demaerel, B. Ghaye, J. Gielen, P. Habibollahi, N. Hottat, M. Laureys, F. Lecouvet, M. Lemmerling, B. Lubicz, J.F. Monville, T. Mulkens, J.F. Nisolle, B. Op de Beeck, R. Oyen, S. Pans, V.P. Parashar (USA), P. Parizel, P. Peene, H. Rigauts, N. Sadeghi, S. Sintzoff Jr, M. Smet, A. Snoeckx, J. Struyven, H. Thierens, P. Van Dyck, F. Vanhoenacker, Ph. Van Hover, J. Verschakelen, K. Verstraete.

Past-President: M. Lemort General Secretaries: F. Avni, J. Verschakelen Executive Secretaries: D. Henroteaux, M. Spinhoven Treasurers: D. Brisbois, A. Van Steen Coordinators of continuing education: E. Coche, G. Villeirs Coordinators of professional defence: C. Delcour, D. Bielen Webmasters: J. de Mey, J. Struyven

Sections of the Royal Belgian Radiological Society (SRBR-KBVR): Abdominal and digestive imaging

B. Op de Beeck, E. Danse

Bone and joints

P. Van Dyck, J.F. Nisolle

Breast imaging

C. Van der Merckt, A. Van Steen

Cardiac imaging

R. Salgado, O. Ghekière

Cardiovascular and interventional radiology

G. Maleux, M. Laureys

Chest radiology

B. Ghaye, W. De Wever

Head and neck radiology

J. Widelec, R. Hermans

Neuroradiology

P. Demaerel, N. Sadeghi

Pediatric radiology

B. Desprechins, L. Rausin

For addresses and particulars, see website at http://www.rbrs.org

Instructions to authors The purpose of The Belgian Journal of Radiology is the publication of articles dealing with diagnostic radiology and related imaging techniques, therapeutic radiology, allied sciences and continuing education. All — new and revised — manuscripts and correspondence should be addressed to JBR-BTR Editorial Office, Avenue W. Churchill 11/30, B-1180 Bruxelles, tel.: 02-374 25 55, fax: 32-2-374 96 28. Please note that the following instructions are based on the “Uniform Requirements for manuscripts Submitted to Biomedical Journals” adopted by the International Committee of Medical Journal Editors (Radiology, 1980,135: 239-243). It should however be noted that presentation modifications may be introduced by the Editorial Office in order to conform with the JBR-BTR personal style. Authors should specify to which of the following headings their manuscript is intended: Original Article, Review Article, Case Report, Pictorial Essay, Continuing Education, Technical Note, Book Review, Opinion, Letter to the Editor, Comment, Meeting News, in Memoriam, News. Authors should consider the following remarks and submit their manuscripts accordingly. All articles must contain substantive and specific scientific material. – Original articles are articles dealing with one specific area of Radiology or allied science related through the personal experience of the author. – Review articles are special articles reporting the experience of the author considered in

–

the general perspective of the literature over the topic. Case reports are short descriptions of a particular case providing a message directly linked to an individuel patient investigated. No more than one case should be described in detail and clinical description should be kept to a minimum. Case reports should invest the usual headings of articles but should focus on the particular radiologic procedure that contributed to the diagnosis. References should be present, though limited in number. Tables and acknowledgements are usually omitted. Pictorial essays are articles presenting information through illustrations and legends. The presentation remarks stated in the paragraph dealing with case reports apply to pictorial essays. Continuing education articles are designed in accordance with the general guidelines for articles published in the JBR-BTR in particular they are divided into introduction, material and methods, results, discussion, references, and are provided with an abstract. However, papers addressing the continuing education may have only additionnally to their contents an introduction (stating the aim of the article and providing any background information useful to understand why the topic is relevant, and describing the subtopics covered by the study), references, and an abstract. Tables should be limited to a maximum of one table per 6 pages of manuscript. Illustrations should also be limited to a maximum of one illustration (1010 cm)

(possibly made up of different parts) per 3 pages of manuscript. All the material should be made available to the JBR- BTR editorial office (2 copies of the manuscript with 2 sets of illustrations) with the corresponding diskette though there will not be peer review. – Images in Clinical Radiology are short (max. 1 typed page) case reports designed to illustrate with max. 3 figures a specific entity. The report should not include abstract nor discussion nor references but consist of a synthetic description of the clinical and radiological features as well as the final diagnosis. Technical notes are short descriptions of a specific technique, procedure or equipment of interest to radiologists. Technical notes may originate from radiologists having experience of the item presented or from commercial firms (these should contact the Editorial Office to obtain specific guidelines for publication). The manuscript length should be inferior to 1 typed page, original language should be English, the manuscript may be accompanied by maximum 1 b/w figure, and include one major reference. – Book reviews should be limited to one typed page, mention full references of the book, including number of pages, of illustrations (when available), and price. The author should specify to whom the book is intended and give a personal appreciation. They will be published with the initial letters of the signature.

(continued on p. VI)

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– Opinion articles are special articles dealing with controversial topics of specific concern to radiologists. They may include tables and figures, and must provide a references list. – Letters to the Editor and their replies present objective and useful criticism over an article published in one of the lest four issues of the JBR-BTR. They will be published with the name and address of the author. References are necessary, tables and figures are accepted but acknowledgements are not appropriate. – Meeting news are reports of national or international congresses, symposia and meetings of radiology. Full references of the meeting, including date, place and summary of the main topics should be mentioned. Text should be kept to major facts. Figures, tables, references and acknowledgements should not be included. – In memoriams and News are essentially dealt with in the Editorial Office. Contributions may however be submitted under the form of letters addressed to the Editorial Office which will check the adequacy of the information.

General Guidelines for Papers Manuscript Requirements Send 3 copies of the manuscript, including tables and figures (1 original set + 2 copies of the text and 2 original sets + 1 copy of the illustrations) and the corresponding diskette (see below Instructions for Electronic Manuscript Submission). In keeping with sound environmental and economic principles, the JBR-BTR encourages all authors to submit manuscripts printed on both sides of the page. The practice not only will save paper but also will reduce the price of postage required to mail the manuscript. Note that failure to provide an electronic version of manuscript will result in costs to be charged to the author. The original set should mention the personal references of the author. The copies should be nameless (including the figures). Each section of the manuscript begins on a new page in the following order: titre page running title page + key-words, abstract, text, acknowledgements, references, tables and captions for illustrations. Use English or one of the national languages. In the latter case, an English version of the titre, abstract, key-words, legends must necessarily be provided. Note that the author will be charged the costs of translation. Submitted manuscripts may not be covered by a previous copyright. The author will be held responsible for any litigation that might possebly ensue. Manuscripts will be submitted to a review Committee whose decision is final. Authors are usually notified within eight weeks as to the acceptability of their paper. Instructions for Electronic Manuscript Submission

Please send an electronic version of your manuscript either a floppy disk or a CD-rom in conjunction with the traditional paper version or separately as an e-mail with attachments to JBR-BTR@skynet.be. Please follow the general instructions on style/ arrangements and, in particular, the reference style as given in the present “Instructions to Authors”. Note, however, that while the paper version of the manuscript must be presented in the traditional double spaced format, the electronic version will be typeset and should not contain any extraneous instructions. For exemple: use hard carriage returns only at the end of paragraphs and display lines (e.g. titles, subheadings); do not use an extra hard return between paragraphs; do not use tabs or extra space at the start of a paragraph or for list entries; do not indent runover lines in references; turn off line spacing; turn off hyphen-

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They should be given as follows: a) abridged titles of periodicals should conform to those in the Index Medicus. All authors are listed when six or fewer; when seven or more authors, the first three are listed, followed by “et al.”. Ex.: Bomsel F., Couchard M., Henry E.: Respiratory distress in the newborn. J Belge Radiol, 1980, 63: 89-107. b) in the case of books, references should indicate: the authors of the chapter, the title of the chapter, the title of the book, the editor(s), publisher, edition, city, year and specific pages. – Ex.: Isengrin P.: Radiologie stomacale. 3e édition, Arscia, Bruxelies, 1974, p. 22. – Ex.: Weinstein L., Swartz M.N.: Pathogenic properties of invading microorganisms. In: Pathologic physiology: mechanisms of disease. Edited by Sodeman W.A. Jr, Sodeman W.A., Cds. Printed by Saunders, Philadelphia, 1974, pp. 457-472. Quote the name and address of the author to whom the reprints will be sent, at the end of the references. Corresponding author and Reprints The name and address of the corresponding author to should be mentioned affer the references. 25 reprints, are offered free by the JBR-BTR. Tables Tables should be presented on a separate page and numbered in Roman numerals in the order in which they are cited in the text. They should have an English title and legend. Abbreviations should be defined in a foot note. Only commonly admitted measurement standards should be used. Figures and Legends Illustrations should be restricted to the minimum required to show the essentiel features described in the paper. They must be mentioned in the text. Two complete unmounted sets of original figures in labeled envelopes should be provided. All figure parts relating to one patient should have the same figure number. Use capital letters A, B, C, in the ieft longer corner to distinguish figures from one set. Figures should be marked on the back with an arabic numeral indicating the sequence in which they are to be referred to, with a lightly pencilled “top“ indicating their topside and the name of the first author. Never use ink on front or back of any figure. For uniformity purposes, points of interest should be showed on the figures with removable (Letraset) arrows or/and letters, or should be indicated on an accompanying photocopy of the figures, in order to enable our services to use their own characters. Images should be uniform in size and magnification. 1. Radiographs Cost and number: depending on the length of the manuscript (a total of 2 to 6 times 14 ⫻ 15 cm is availabie free of charge). Presentation: glossy prints, no larger than 18/24 cm. It is advisable for films to be centered on the zone of major interest and they should be grouped. Arrows should indicate the important points. 2. Photographs and drawings Four-colour illustrations will be printed at the expense of the authors. Drawing and graphs should be of professional quality. They should illustrate — not duplicate — data given in the text. Legends are typed separately and preceded by the number of the corresponding illustration. Note that illustrations will not be returned to authors.

(*) Pr J. PRINGOT, Avenue W. Churchill 11/30, B-1180 Bruxelles, Belgique (tél.: 02-374.25.55, fax: 02-374.96.28, e-mail: JBR-BTR@skynet.be).

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1. NAAM VAN HET GENEESMIDDEL: MultiHance, 0.5 M oplossing voor injectie. 2. KWALITATIEVE EN KWANTITATIEVE SAMENSTELLING: 1 ml oplossing voor injectie bevat: 334 mg gadobeenzuur (0,5 M) als het dimeglumine-zout [gadobeendimeglumine 529 mg = gadobeenzuur 334 mg + meglumine 195 mg]. Voor hulpstoffen, zie 6.1. 3. FARMACEUTISCHE VORM: Oplossing voor injectie. Heldere waterige oplossing, afgevuld in kleurloze glazen flacons. Osmolaliteit bij 37 ºC: 1,97 osmol/kg. Viscositeit bij 37 ºC: 5,3 mPa.s. 4. KLINISCHE GEGEVENS: Therapeutische indicaties: Dit geneesmiddel is uitsluitend bestemd voor diagnostisch gebruik. MultiHance is een paramagnetische contrastvloeistof die wordt gebruikt voor de magnetische resonantie tomografie (MRI) geïndiceerd voor: MRI van de lever voor de detectie van focale leverlaesies bij patiënten met bekende of verdachte primaire leverkanker (b.v. hepatocellulair carcinoom) of metastasen. MRI van de hersenen en het ruggenmerg, waar het de detectie van laesies verbetert en aanvullende diagnostische informatie kan geven op de informatie uit de niet contrast-versterkte MRI. Contrastversterkte MR-angiografie (MRA) bij patiënten met verdachte of bekende vasculaire ziekten van de abdominale of perifere arteriën. Dosering en wijze van toediening: MRI van de lever: de aanbevolen dosis MultiHance bij volwassenen bedraagt 0,05 mmol/kg lichaamsgewicht, hetgeen overeenkomt met 0,1 ml/kg van de 0,5 M oplossing. MRI van de hersenen en het ruggenmerg: de aanbevolen dosis MultiHance bij volwassenen is 0,1 mmol/kg lichaamsgewicht hetgeen overeenkomt met 0,2 ml/kg van de 0,5 M oplossing. MRA: de aanbevolen dosis MultiHance bij volwassenen is 0,1 mmol/kg lichaamsgewicht hetgeen overeenkomt met 0,2 ml/kg van de 0,5 M oplossing. MultiHance moet onmiddellijk voor het gebruik in de injectiespuit worden opgezogen en mag niet worden verdund. Eventuele ongebruikte restanten contrastvloeistof moeten worden vernietigd, en mogen niet worden gebruikt voor ander MRI onderzoek. Om de mogelijke risico’s van extravasatie van MultiHance in het spierweefsel te voorkomen dient men erop toe te zien dat de i.v. naald of canule zorgvuldig in de vena wordt aangebracht. Lever en hersenen en ruggenmerg: de oplossing dient intraveneus te worden toegediend als bolus of als langzame injectie (10 ml/min.). MRA: de oplossing dient intraveneus als een bolus injectie te worden toegediend, handmatig of gebruikmakend van een automatisch injecteersysteem. Na de injectie dient een spoeling met fysiologische zoutoplossing plaats te vinden. Post-contrast tomogrammen acquisitie: Lever

Dynamische tomografie:

Onmiddellijk na een bolus injectie.

Vertraagde tomografie:

Tussen de 40 en 120 minuten na de injectie, afhankelijk van de individuele tomografische behoefte.

1. DENOMINATION: MultiHance 0,5 mmol/ml solution injectable. 2. COMPOSITION QUALITATIVE ET QUANTITATIVE: MultiHance 0,5 mmol/ml solution injectable. COMPOSITION QUALITATIVE ET QUANTITATIVE : 1 mL de solution contient : acide gadobénique 334 mg (0,5 M) sous forme de sel de diméglumine. [529 mg de gadobénate de diméglumine = 334 mg d’acide gadobénique + 195 mg de dimglumine]. Pour les excipients, cf. 6.1. 3. FORME PHARMACEUTIQUE: Solution injectable. Solution aqueuse limpide, incolore, remplie dans des flacons de verre incolore. Osmolalité à 37°C : 1,970 Osmol/kg. Viscosité à 37°C : 5,3 mPa.s. 4. DONNEES CLINIQUES: Indications thérapeutiques: Ce médicament est à usage diagnostique uniquement. Produit de contraste paramagnétique utilisé dans l’imagerie par résonance magnétique (IRM) et indiqué dans : IRM du foie pour la détection des lésions hépatiques lorsqu’un cancer hépatique secondaire ou primitif (carcinome hépatocellulaire) est suspecté ou connu. IRM du cerveau et de la moelle épinière où il améliore la détection des lésions et apporte des informations diagnostiques supplémentaires comparativement à une IRM sans produit de contraste. Angiographie par résonance magnétique (ARM) où il améliore l’exactitude diagnostique pour la détection de la maladie vasculaire sténo-occlusive cliniquement significative lorsqu’une pathologie vasculaire des artères abdominales ou périphériques est suspectée ou connue. Posologie et mode d’administration: IRM du foie: La dose recommandée chez l’adulte est de 0,05 mmol/kg de poids corporel, soit 0,1 ml/kg de la solution 0,5 M. IRM du système nerveux central: La dose recommandée chez l’adulte est de 0,1 mmol/kg de poids corporel, soit 0,2 ml/kg de la solution 0,5 M. ARM: La dose recommandée chez l’adulte est de 0,1 mmol/kg de poids corporel, soit 0,2 ml/kg de la solution 0,5 M. MultiHance doit être introduit dans la seringue immédiatement avant l’injection et ne doit pas être dilué. Tout reliquat éventuel doit être jeté et ne doit pas être utilisé pour d'autres examens IRM. Pour diminuer le risque d’extravasation de MultiHance dans les tissus mous environnants, il est conseillé de s’assurer de la bonne disposition de l’aiguille ou de la canule dans la veine. Foie et système nerveux central : le produit doit être administré par voie intraveineuse soit en bolus soit en injection lente (10 mL/min). ARM: le produit doit être administré par voie intraveineuse en bolus, soit manuellement soit à l’aide d’un injecteur automatique. L’injection doit être suivie d’un bolus de chlorure de sodium à 0,9%. Acquisition des images post-contraste: Foie

Imagerie dynamique

Immédiatement après l’injection en bolus

Imagerie retardée

Entre 40 et 120 minutes après l’injection (IRM retardée), en fonction du type d’imagerie nécessaire

Hersenen en ruggenmerg

Tot 60 minuten na toediening.

Système nerveux central

Jusqu’à 60 minutes après administration

MRA

Onmiddellijk na toediening, met scan vertraging die op basis van de testbolus of automatische bolus detectie techniek wordt berekend.Indien een automatische contrastdetectie puls-sequentie niet wordt gebruikt voor bolus timing, dan dient een test bolus injectie <2 ml van de oplossing gebruikt te worden om de geschikte scan vertraging te berekenen.

ARM

Immédiatement après l’administration, avec un délai d’acquisition calculé sur la base du bolus test ou par la technique de détection automatique du bolus. Si la détection automatique du contraste en séquence pulsée n’est pas utilisée, alors l’injection d’un bolus test de 2 mL de produit au maximum devra être réalisée pour calculer le timing d’acquisition adéquat.

De veiligheid en de werkzaamheid van MultiHance zijn niet vastgesteld bij patiënten beneden 18 jaar. Het gebruik van MultiHance bij deze patiëntengroep wordt derhalve niet aanbevolen. Contra-indicaties: MultiHance dient niet te worden toegepast bij patiënten met een overgevoeligheid voor één van de bestanddelen. MultiHance mag eveneens niet worden toegepast bij patiënten die eerder allergische reacties of andere bijwerkingen ondervonden ten gevolge van andere gadoliniumchelaten. 5. HOUDER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN: Bracco Imaging Deutschland GmbH, Max-Stromeyer-Straße 116, 78467 Konstanz, Duitsland. 6. NUMMER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN: MultiHance 5 ml: BE199963, MultiHance 10 ml: BE199972, MultiHance 15 ml: BE19998, MultiHance 20 ml: BE199997. 7. DATUM VAN EERSTE VERLENING VAN DE VERGUNNING/HERNIEUWING VAN DE VERGUNNING: Datum eerste verlening van de vergunning: 22 juli 1997. Datum laatste renewal: 21 juli 2007. 8. DATUM VAN HERZIENING VAN DE TEKST: Augustus 2008. Goedkeuringsdatum: 09/2008. 9. AFLEVERINGSWIJZE: Geneesmiddel op medisch voorschrift.

La sécurité d’emploi et l’efficacité de MultiHance n’ont pas été établies chez les sujets de moins de 18 ans. Par conséquent, l’utilisation de MultiHance dans cette population n’est pas recommandée. Contre-indications: MultiHance est contre-indiqué chez les patients présentant une hypersensibilité à l’un de ses constituants. MultiHance ne doit pas être utilisé chez les patients ayant des antécédents d’allergie ou d’effet indésirable liés à d’autres chélates de gadolinium. 5. TITULAIRE DE L’AUTORISATION DE LA MISE SUR LE MARCHE: Bracco Imaging Deutschland GmbH Max-Stromeyer-Straße 116, 78467 Konstanz Allemagne. 6. NUMERO(S) D’AUTORISATION DE MISE SUR LE MARCHE: MultiHance 5 ml: BE199963, MultiHance 10 ml: BE199972, MultiHance 15 ml: BE199981, MultiHance 20 ml: BE199997. 7. DATE DE PREMIERE AUTORISATION/DE RENOUVELLEMENT DE L’AUTORISATION: Date de première autorisation: 22 juillet 1997. Date de dernier renouvellement: 21 juillet 2007. 8. DATE DE MISE A JOUR DU TEXTE: Août 2008. Date d’approbation: 09/2008. 9. STATUT LEGAL DE DELIVRANCE: Médicament soumis à préscription médicale.

www.bracco.com

Prix hosp. / prijs ziekenhuis: 10 ml 15 ml 20 ml

e 47,60 e 68,05 e 82,08

MAGNETIC RESONANCE

MR Angiography with MultiHance ® :

detection of significant steno-occlusive disease of the abdominal or peripheral arteries • MultiHance® is now also indicated for Contrast-enhanced MR-angiography where it improves the diagnostic accuracy for detecting clinically significant steno-occlusive vascular disease in patients with suspected or known vascular disease of the abdominal or peripheral arteries.(1)

MH_MRA_3-03-08ADV

• The recommended dose of MultiHance® injection in adult patients is 0.1 mmol/kg body weight. This corresponds to 0.2 mL/kg of the 0.5 M solution.(1)

Reference: 1. Multihance Spc Please consult locally approved information.

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JBR–BTR, 2011, 94: 169-177.

REVIEW ARTICLE LIVER METASTASES W. Schima1, C. Koelblinger2, G. Lesnik3, A. Ba-Ssalamah2 Liver metastases are a very common site of distant metastases. Detection and accurate characterization of liver metastases is of importance to guide therapy. A variety of imaging modalities such as US (including contrast agents), MDCT, MRI with liver –specific contrast agents and PET/CT are available for this purpose. This review presents imaging techniques and summarizes the current knowledge, how the different imaging modalities should be used. Key-word: Liver neoplasms, metastases.

Liver metastases are very common in oncologic patients. Early detection and accurate characterization of liver metastases is of great importance in cancer patients regarding prognosis and further patient management. In general, the presence of liver metastases indicates non-resectability of the primary tumor for oncologic reasons and chemotherapy is the treatment of choice. However, in colorectal cancer patients resection of liver metastases has been shown to improve patient survival (1). In patients with colorectal cancer with metastatic spread confined to the liver, liver resection offers the only chance of cure. The 5-year survival rate following surgery is 25-40% in comparison to 0-10% in patients treated non-surgically (1-3). However, only a minority of patients (up to 15%) with colorectal liver metastases are amenable for resection due to the number, location and size of liver metastases or the presence of extrahepatic disease. Thus, accurate staging by imaging plays a crucial role to identify patients, who may benefit from resection. In patients with suspected liver metastases undergoing chemotherapy imaging is also crucial. It is essential to assess therapy response accurately and reproducibly. Therefore a radiologic examination in patients with suspected liver metastases should provide high sensitivity and specificity, should be non-invasive and allow detection of extrahepatic disease (4). This review will discuss the appearance of liver metastases at various imaging modalities and their

From: 1. Abteilung für Radiologie und bildgebende Diagnostik, KH Göttlicher Heiland, Vinzenzgruppe, Vienna, 2. Department of Radiology, Medical University of Vienna, Vienna, 3. Institut für Diagnostische und Interventionelle Radiologie, Klinikum Klagenfurt, Klagenfurt, Austria. Address for correspondence: Doz Dr W. Schima, Abteilung für Radiologie und bild gebende Diagnostik, KH Göttlicher Heiland, Vinzenzgruppe, Dornbacher Strasse 20–28, 1170 Vienna, Austria.

Fig. 1. — Contrast-enhanced ultrasound for characterization of liver lesions. A. Hypoechoic adenocarcinoma metastasis shows rapid enhacement after contrast agent administration with washout (arrows) in the liver-specific phase. B. Necrotic metastases from small cell lung cancer appear very hypoechoic. After contrast agent administration there is only minimal rim enhancement and no enhancement of the necrotic center.

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JBR–BTR, 2011, 94 (4)

appropriate use of imaging in patients with liver metastases. Sonography

Fig. 2. — Ultrasound contrast agent for characterization and detection. Fundamental phase image shows almost isoechoic adenocarcinoma metasis with hypoechoic rim. After contrast agent there is rim enhancement of the lesion with wash-out (arrows). In the liver-specific phase, multiple additional lesions are visualized (arrowheads).

Fig. 3. — Biphasic contrast-enhanced CT scan in a patient with colo-rectal liver metastases. A. Arterial-phase scan does not show liver metastases. Artifacts are due to arterial port. B. The venous-phase image clearly demonstrates three hypoattenuating metastases.

Real-time ultrasound provides a rapid and non-invasive method to examine patients with suspected right upper quadrant disease. Hepatic metastases may be hypoechogenic, hyperechogenic, isoechogenic, even anechogenic (cystic) or of mixed echogenicity (5). The hypoechoic pattern is most common and it may be observed in any type of primary tumor. Sensitivity of grey scale US for detection of liver metastases is quite low and may even drop to 20% for lesions smaller than 1 cm (6, 7). Therefore several technical efforts have been made to increase the diagnostic power of sonography. Tissue harmonic imag-

Fig. 4. — Typical enhancement features of liver metastases. A. Metastases of neuroendocrine cancer („carcinoid“) are hypervascular in arterial phase. B. Adenocarcinoma metastases (e.g., of colo-rectum, pancreas, stomach, esophagus) are typically hypodense with rim enhancement.

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Fig. 6. — Melanoma metastasis. A. the T1w GRE in-phase image show s hyperintense lesion. High signal intensity can be due to hemorrhage, melanin or fat. B. On the T1w GRE opposed phase the lesion stays hyperintense, which excludes the presence of fat. High signal intensity is due to melanin content in melanoma metastasis.

C Fig. 5. — Unenhanced MRI of colon cancer metastasis. A. Lesion is hypointense on the T1-w GRE image. B. Metastasis shows moderate hyperintensity on the fat-suppressed T2w TSE image. C. The diffusion-weighted image with a high b-value of 600 mm2/s demonstrates typical high signal of metastasis due to restricted diffusion in the lesion.

ing detects the reflected harmonic response of a transmitted pulse and improves signal-to-noise ratio, and better spatial resolution due to the higher receiver frequency. US contrast agents, which consist of gas-filled microbubbles typically smaller than 8µm surrounded by a stabilizing layer and dissolved in water, were developed to increase the diagnostic accuracy of US for tumor detection and characterization. After IV injection of these blood-pool agents, depending on the sound pressure, different mechanisms produce augmentation of signal in the vascular system for several minutes as the microbubbles do not leave the intravascular space. Contrast-enhanced US (CEUS) allows dynamic imaging with a very high temporal resolution, not only as a

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B Fig. 8. — The value of liver-specific contrast agents. A. Gadoxetic acid-enhanced MRI in the venous phase shows 2 liver metastases. B. The delayed-phase image shows two addditional small subcapsular lesions (arrrows) not well seen in the venous phase.

C Fig. 7. — Dynamic gadolinium-enhanced MRI of colon cancer metastasis. A-C Dynamic contrast-enhanced MRI in the arterial (A), venous (B), and equilibrium-phase (C) shows rim enhancement in the venous phase and peripheral wash-out (arrow), which is quite specific for malignancy.

single acquisition in the arterial, portal-venous, and delayed phase, as in CT. Different focal liver lesions show quite distinct enhancement features, due to the high temporal resolution of CEUS. Metastases are either hypoechogenic or hyperechogenic in the arterial phase and usually hypoechogenic in the portal venous and the delayed vascular phase due to contrast agent washout (8) (Fig. 1). In contrast, hemangiomas typically show peripheral and centripetal enhancement with sustained enhancement in the delayed phase due to vascular pooling. Compared to standard grey-scale US, CEUS allows better detection and characterization of focal liver lesions. In the study of von Herbay et al. the use of CEUS improved the sensitivity and specificity of US in the differentiation of malignant vs.

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C Fig. 9. â&#x20AC;&#x201D; Value of PET/CT A, B. PET/CT not only shows a solitary hypermetabolic metastasis in the right liver lobe, but also the primary tumor in the sigmoid colon (arrow). C. After resection of the liver metastasis, the contrast-enhanced CT data set (of the PET/CT examination) shows the wedge-shaped resection defect and a clip. D. Fused PET/CT demonstrates low metabolism in the resection defect, thus excluding tumor recurrence.

benign from 78% to 100% and from 23% to 92%, respectively (9). In a large multicenter trial the addition of contrast-enhanced ultrasound increased the sensitivity of detection of metastases on a per-lesion basis

D from 71% (standard US) to 87% (Fig. 2). Thus the guidelines of EFSUMB for the use of contrast agents in ultrasound recommend

the use of US contrast agents in oncologic patients to clarify a questionable lesion detected at baseline examination (10).

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Fig. 10. â&#x20AC;&#x201D; DWI and gadolinium-enhanced MRI at 3.0T is superior to MDCT. A. At MDCT three small metastases are visualized, with low contrast. B. T2w MRI at 3.0T shows many more hyperintense metastases. C. At DWI the lesions are displayed with excellent conspicuity. D. Gadolinium-enhanced MRI shows typical rim enhancement of metastases.

Multidetector-row CT (MDCT) Computed tomography (CT) is the most widely used imaging modality for detection and characterization of hepatic metastases. With the advent of MDCT scanners thin-slice imaging of the entire liver within one breathhold has become possible. The new 256+-row detector scanners allow imaging of the liver in 1-2 seconds, which renders appropriate timing and contrast material administration and scanning crucial. An unenhanced scan may be helpful for assessment of diffuse liver steatosis and characterization of small focal lesions. However, recent studies have shown that a virtual scan in patients, who undergo dual energy CT, will be able to replace true unenhanced scans (11). A biphasic scan after contrast mate-

rial administration in the arterial and the venous phases is recommended to optimize metastasis detection and characterization (12) (Fig. 3). Some primary tumors will seed hypervascular liver metastases (e.g., neuroendocrine tumor, renal cancer, sarcomas, etc.), whereas most liver metastases will be hypovascular (adenocarcinoma in colorectal, pancreatic, gastric or esophageal primaries) (Fig. 4). For follow-up studies in patients with primary tumors known to seed hypovascular metastases (e.g., colorectal cancer) a single scan in the venous phases may suffice as radiation exposure is an important issue in patients undergoing several follow-up studies. Weg et al. showed that the use of 2.5 mm thick slices results in a 86% increase in the detection rate of small (< 1 cm) liver

lesions compared to 10 mm thick sections (13). These results have been corroborated by Kopka et al., who found that a slice thickness of 3.75 mm was superior to 5 mm in terms of lesion detection (14). Further decrease of slice thickness to 1 mm will only increase image noise. Therefore overlapping slices with a thickness of 2-4 mm is recommended for axial viewing. Multiplanar reconstructions (MPR) in coronal plane improve subcapsular lesion detection. Magnetic Resonance Imaging (MRI) With its inherent high soft tissue contrast MRI has been found to be the most sensitive technique for detection of liver metastases. One of the major challenges of liver MR imaging is to overcome motion arti-

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Fig. 11. â&#x20AC;&#x201D; Mangafodipir-enhanced MRI is superior to contrast-enhanced MDCT for lesion detection. A. The mangafodipir-enhanced T1w GRE images shows a small lesion in the right lobe (arrow). B. The lesion is only faintly seen at MDCT.

facts due to breathing, gastric peristalsis, and cardiac or aortic pulsation. Multi-channel torso coils are now standard in body MR imaging and a field strength of 3.0 T is preferable. The standard MRI protocol should always include unenhanced T1- and T2-weighted, diffusionweighted images (DWI), and contrast-enhanced sequences (Fig. 5). To assess liver or lesion fat content unenhanced T1 weighted in- and opposed-phased GRE sequences are necessary. Turbo-spin echo (TSE) (synonym: fast spin echo, FSE) with fat saturation are preferred for T2weighted imaging. Typically liver metastases are hypointense on T1-weighted images with the exception of melanoma or hemorrhagic metastases, which may be hyperintense due to melanin or methemoglobin content, respectively (Fig. 6). Most metastases are moderately hyperintense on T2-weighted images (15). However, the signal intensities of hepatic metastases can vary. In cystic metastases (e.g., ovarian cancer) or when liquefactive necrosis or mucin is present, signal intensity on T2-weighted images increases. In these cases only dynamic gadolinium-enhanced imaging will help in the differentiation of small metastases from cysts or hemangiomas (16). Due to increased cellularity water molecule diffusion is restricted in most types of liver metastases, which can be utilised by diffusionweighted MR imaging. Due to restricted diffusion of water molecules, metastases appear hyperintense on DWI images using a high b-

value of 500-1000 mm/s (17-19) (Fig. 5). Several studies showed that the use of DWI improves the detection of focal liver lesions (17, 18). Even as an adjunct to MRI with liverspecific contrast agents, DWI may improve lesion detection (19). Recent studies suggest that DWI may also help in the characterization of focal hepatic lesions using the apparent diffusion coefficient (ADC), although further studies are needed to corroborate these findings (20). DWI of the liver is prone to motion and susceptibility artefacts in the left lobe, which often impairs image quality at 3.0T. Image quality is therefore more predictable at 1.5T. Contrast-enhanced MRI After intravenous bolus injection non-specific gadolinium chelates (extracellular contrast agents) are distributed in blood vessels and rapidly diffuse into the extracellular space. Liver lesions show MRI enhancement patterns similar to those obtained with contrastenhanced CT. Several agents are available, being injected IV as a bolus at a standard dosage 0.1 mmol/kg body weight. Routinely dynamic axial T1-w GRE images are obtained at least in the arterial, the venous, and the equilibrium phases (at 3-5 min post injection). Most liver metastases are hypovascular (e.g., from colorectal, gastric, pancreatic and esophageal cancer) and similar to CT can be delineated best in the venous phase. Some metastases, especially from renal or neuroendocrine cancer, are hypervascular

and therefore best depicted in the arterial phase. The equilibrium phase is important for lesion characterization. Hemangiomas typically show persistent gadolinium pooling at this time point, whereas most metastases appear hypointense or centrally isointense with peripheral washout sign (21) (Fig. 7). Cystic metastases will show a blurred edge in the equilibrium phase compared to the non-enhanced images, because contrast material diffuses into the tumor periphery, which helps in the differentiation from simple cysts. The two most common patterns of enhancement of hypoand hypervascular lesions in the arterial phase both are peripheral ring enhancement (72%) and heterogeneous enhancement (17%) (22) (Fig. 7). Homogeneous hyperintense enhancement in the arterial phase is typically found in small (< 1.5 cm) hypervascular metastases whereas larger lesions (> 3 cm) tend to be heterogeneous. Perilesional enhancement is often found in hypovascular metastases with a wedgeshaped pattern probably resulting from portal venous obstruction or venous shunting. However, this pattern is also observed in hemangiomas, which limits its value for lesion characterization. In contrast to non-specific gadolinium chelates, which are distributed into the extracellular space, liver-specific contrast agents are taken up intracellularly either by hepatocytes (hepatobiliary contrast agents) or by Kupffer cells, e.g. cells of the reticuloendothelial system of the liver. Unfortunately, the reticulo-

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endothelial liver-specific contrast agents and the hepato-biliary contrast agent mangafodipir (Teslascan®, GE Healthcare) have been withdrawn from the market recently, leaving two contrast agents available, which combine extracellular and hepatobiliary properties (hybrid contrast agents). Gadobenate dimeglumine (MultiHance®, Bracco, formerly known as Gd-BOPTA), and gadoxetic acid (Primovist®, Bayer, formerly known as Gd-EOB-DTPA), are hybrid gadolinium based contrast agents, which carry a lipophilic ligand (23). After IV bolus injection these agents show rapid biphasic liver enhancement with the first phase similar to that of non-specific gadolinium chelates. Due to their ligand a fraction of the injected dose is taken up by the hepatocytes, which leads to a SI increase on T1-weighted images. The contrast agent component is washed out from the extracellular compartment, which results in improved contrast between liver and metastases on delayed-phase images (gadoxetic acid: 20 min, gadobenate 60 min post injection) (23, 24) (Fig. 8). PET and PET-CT By far the most commonly used tracer for PET imaging of liver metastases is 2-[18F] fluoro-2-deoxyD-glucose (FDG). Tumor imaging with this tracer is based on the principle that cancer typically has an increased glucose uptake and an altered intracellular glucose metabolism, which traps 18F-FDG in the cells. The PET scanner detects the positrons emitted by the decaying 18F and represents this visually. Metabolic activity of tumors can be assessed by calculating the standardized uptake value (SUV). However, 18F-FDG also accumulates in normal liver tissue, resulting in high background, which limits the detection of hypermetabolic liver metastases. FDG-PET is a valuable tool in the detection of hepatic metastases (25, 26). Especially in patients with equivocal CT and MR findings and for detection of tumor recurrence FDG-PET has been helpful (27). PET-CT scanners combine the functional information obtained from a PET scan with the anatomic information of a MDCT scan. If adequate contrast-enhanced CT scanning protocols are used, it is the imaging modality of choice to detect extrahepatic disease (28) (Fig. 9).

JBR–BTR, 2011, 94 (4)

Which is the best modality? There is an ongoing debate, which imaging modality offers the best and cost-effective assessment of liver metastases (4). A recent meta-analysis of Niekel et al. has compared the diagnostic value of CT, MRI, PET, and PET/CT in the evaluation of colorectal liver metastases derived from studies published between 1990 and 2010 (29). The authors found that MRI was the most sensitive method for detection of metastases. Especially for detection of small metastases it was superior to contrast-enhanced CT. There were too few studies on PET/CT to be included in the analysis to draw further conclusions (29). Interestingly, this meta-analysis did not find any benefit of contrast-enhanced MRI over unenhanced MRI (including DWI). Generally MDCT scanning is used as a screening examination of the liver in most institutions as it is a robust, widely available and valuable imaging technique and moreover allows the assessment of extrahepatic disease (chest, abdomen, and pelvis). PET scanning is not used routinely in the initial assessment of oncologic patients because of its cost, poor spatial resolution and lack of anatomic information. Moreover it is not superior to MDCT in the initial staging of primary colorectal cancer. Depending on local availability and user experience contrastenhanced ultrasound may be an option for initial liver assessment with sensitivity for liver metastasis detection comparable to that of MDCT. Unenhanced ultrasound of the liver, however, is now obsolete in oncologic patients due to its low sensitivity for lesion detection. Only a few studies compared MDCT and MRI regarding liver evaluation. It was demonstrated that MRI, either gadolinium-enhanced or with liverspecific SPIO contrast agents, demonstrates a higher diagnostic accuracy than MDCT for detection and characterization of focal liver lesions (30) (Figs. 10, 11). Compared to helical CT multiple studies have shown that MRI with different contrast agents is superior regarding lesion detection and characterization (31, 32). MRI is routinely used in patients with unequivocal CT scans or with contraindications to a CT examination. It should also be used in patients with severe liver steatosis as this condition markedly decreases the diagnostic performance of US and CT in liver evaluation. Moreover

it plays a major role in the assessment of patients who are eligible for resection of liver metastases. Diagnostic value of preoperative MDCT and MRI Preoperative imaging capabilities with CT and MRI in patients with colorectal liver metastases have dramatically improved in the last decade. It has been shown that with the use of state-of-the-art MDCT and/or MRI combined with a multidisciplinary preoperative evaluation additional liver metastases will only be found in 8% of patients during surgery (33). MRI with non-specific gadolinium chelates or liver-specific agents has been shown to be superior to MDCT for detection of liver metastases. Because of the higher sensitivity of MRI regarding liver metastases detection and the better characterization of small lesions a preoperative MR study with liverspecific contrast agent is recommended in all patients (4). Conclusion In conclusion, contrast-enhanced chest and abdomen MDCT and liver MRI (with liver-specific contrast agents if available) are recommended for an optimal preoperative evaluation of patients undergoing liver metastasis resection. It has to be shown if PET/CT will prove its diagnostic efficacy to replace CECT in this indication.

References 1. Lodge J.P.: Modern surgery for liver metastases. Cancer Imaging, 2000, 1: 77-85. 2. Nordlinger B., Van Cutsem E., Rougier P., et al.: Does chemotherapy prior to liver resection increase the potential for cure in patients with metastatic colorectal cancer? A report from the European Colorectal Metastases Treatment Group. Eur J Cancer, 2007, 43: 2037-2045. 3. Rees M., John T.G.: Current status of surgery in colorectal metastases to the liver. Hepatogastroenterology, 2001, 48: 341-344. 4. Kölblinger C., Lesnik G., Ba-Ssalamah A., Schima W.: Liver Metastases. In: Husband J.E., Reznek R.H. (eds.). Imaging in Oncology, 3rd ed. Informa Healthcare, 2010. p. 1021-1047 5. Viscomi G.N., Gonzalez R., Taylor K.J.: Histopathological correlation of ultrasound appearances of liver metastases. J Clin Gastroenterol, 1981, 3: 395-400.

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LIVER METASTASES â&#x20AC;&#x201D; SCHIMA et al 6. Albrecht T., Hoffmann C.W., Schmitz S.A., et al.: Phase-inversion sonography during the liver-specific late phase of contrast enhancement: improved detection of liver metastases. AJR Am J Roentgenol, 2001, 176: 1191-1198. 7. Wernecke K., Rummeny E., Bongartz G., et al.: Detection of hepatic masses in patients with carcinoma: comparative sensitivities of sonography, CT, and MR imaging. AJR Am J Roentgenol, 1991, 157: 731-739. 8. Brannigan M., Burns P.N., Wilson S.R.: Blood flow patterns in focal liver lesions at microbubble-enhanced US. Radiographics, 2004, 24: 921-935. 9. von Herbay A., Vogt C., Willers R., Haussinger D.: Real-time imaging with the sonographic contrast agent SonoVue: differentiation between benign and malignant hepatic lesions. J Ultrasound Med, 2004, 23: 1557-1568. 10. Albrecht T., Blomley M., Bolondi L., et al.: Guidelines for the use of contrast agents in ultrasound. January 2004. Ultraschall Med, 2004, 25: 249-256. 11. De Cecco C.N., Buffa V., Fedeli S., et al.: Dual energy CT (DECT) of the liver: conventional versus virtual unenhanced images. Eur Radiol, 2010, 20: 2870-2875. 12. van Leeuwen M.S., Noordzij J., Feldberg M.A., Hennipman A.H., Doornewaard H.: Focal liver lesions: characterization with triphasic spiral CT. Radiology, 1996, 201: 327-336. 13. Weg N., Scheer M.R., Gabor M.P.: Liver lesions: improved detection with dual-detector-array CT and routine 2.5-mm thin collimation. Radiology, 1998, 209: 417-426. 14. Kopka L., Grabbe E. [Biphasic liver diagnosis with multiplanar-detector spiral CT]. Radiologe, 1999, 39: 971978. 15. Schima W., Saini S., Echeverri J.A., Hahn P.F., Harisinghani M., Mueller P.R.: Focal liver lesions: characterization with conventional spin-echo versus fast spin-echo T2weighted MR imaging. Radiology, 1997, 202: 389-393. 16. Bennett G.L., Petersein A., MayoSmith W.W., Hahn P.F., Schima W., Saini S.: Addition of gadolinium

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chelates to heavily T2-weighted MR imaging: limited role in differentiating hepatic hemangiomas from metastases. AJR Am J Roentgenol, 2000, 174: 477-485. Low R.N., Gurney J.: Diffusionweighted MRI (DWI) in the oncology patient: value of breathhold DWI compared to unenhanced and gadolinium-enhanced MRI. J Magn Reson Imaging, 2007, 25: 848-858. Parikh T., Drew S.J., Lee V.S., Wong S., Hecht E.M., Babb J.S., Taouli B.: Focal liver lesion detection and characterization with diffusion-weighted MR imaging: comparison with standard breath-hold T2-weighted imaging. Radiology, 2008, 246: 812-22. Koh D.M., Brown G., Riddell A.M., et al.: Detection of colorectal hepatic metastases using MnDPDP MR imaging and diffusion-weighted imaging (DWI) alone and in combination. Eur Radiol, 2008, 18: 903-910. Bruegel M., Holzapfel K., Gaa J., et al.: Characterization of focal liver lesions by ADC measurements using a respiratory triggered diffusion-weighted single-shot echo-planar MR imaging technique. Eur Radiol, 2008, 18: 477485. Mahfouz A.E., Hamm B., Wolf K.J.: Peripheral washout: a sign of malignancy on dynamic gadoliniumenhanced MR images of focal liver lesions. Radiology, 1994, 190: 49-52. Danet I.M., Semelka R.C., Leonardou P., et al.: Spectrum of MRI appearances of untreated metastases of the liver. AJR Am J Roentgenol, 2003, 181: 809-817. Reimer P., Schneider G., Schima W.: Hepatobiliary contrast agents for contrast-enhanced MRI of the liver: properties, clinical development and applications. Eur Radiol, 2004, 14: 559-578. Raman S.S., Leary C., Bluemke D.A., et al.: Improved characterization of focal liver lesions with liver-specific gadoxetic acid disodium-enhanced magnetic resonance imaging: a multicenter phase 3 clinical trial. J Comput Assist Tomogr 2010, 34: 163-172. Herbertson R.A., Lee S.T., Tebbutt N., Scott A.M.: The expanding role of PET technology in the management of

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IMAGING OF BLADDER CANCER: UPDATE ON CURRENT APPROACHES FOR DIAGNOSIS B. Turkbey1, E. Bengi Turkbey1, G. Ravizzini2, M. Karcaaltincaba1 Imaging plays a mainstay role in evaluation of patients with bladder cancer, especially for diagnosis, local and distant staging and treatment follow up. In this article, we aim to review and to update conventional and functional imaging methods used in clinical management of bladder cancer. Key-word: Bladder neoplasms, diagnosis.

Bladder cancer is the fourth most common cancer among men in the United States (1). It has a propensity to be multifocal with a high rate of recurrence. Therefore, it requires reliable diagnostic work-up. Despite new emerging imaging technologies, the diagnosis of bladder cancer is based on cystoscopic visualization and tissue sampling by means of biopsy and excision. The majority of newly diagnosed bladder cancers are low grade and noninvasive. But high grade disease, which manifests as local invasion, adjacent organ extension, and distant metastases, can also occur. As pretreatment staging highly affects the treatment approach and survival, accurate imaging work-up is almost always needed. Herein, we will review the imaging modalities used in the detection of bladder cancer and local staging. Ultrasonography Ultrasonography (US) is a widely used, inexpensive, easily performed, and repeatable non-invasive imaging modality. US is the first line imaging method for bladder pathologies (2). US examination of the bladder requires adequate distension of the bladder, which can be accomplished by ingesting water or other fluids. In the majority of cases, a transabdominal approach is enough for accurate evaluation of bladder walls if adequate distention is present. Occasionally, a transrectal or a transvaginal approach can be used if the bladder neck or trigone needs to be evaluated. On US, bladder cancer lesions can appear as papillary, infiltrating, invasive or mixed. Papillary lesions appear as small echogenic masses projecting from the bladder wall which can

Fig. 1. â&#x20AC;&#x201D; Transabdominal ultrasound image of a male with bladder cancer demonstrates mixed type (papillary and infiltrating) tumor lesions at posterior wall of bladder (arrows).

usually be detected when they reach a diameter of 2-3 mm. Infiltrating lesions appear as hypo-echogenic masses with bladder wall disruption, they can bear papillary component and can be detected soon after they reach a diameter of 5 mm (Fig. 1, 2). Infiltrating lesions can be associated with wall rigidity and asymmetric bladder distension. Color and/or power Doppler mode can be used to ascertain the pattern of flow within the lesion, moreover can be helpful to distinct a focal mass from a clot (3). Despite its operator experience dependency; US allows visualization of all bladder cancers greater than 5mm in diameter, provided that it is optimally distended (2). Computed tomography (CT) Multidetector computed tomography (MDCT) is the method of choice for the assessment of gross hematuria and suspected urothelial tumor.

From: 1. Department of Radiology, Hacettepe University, School of Medicine, Ankara, Turkey and 2. Department of Radiology, State University of New York Upstate Medical University, Syracuse, NY, USA. Address for correspondence: Dr B. Turkbey, M.D., HUTF Radyoloji AD, Sihhiye 06100, Ankara, Turkey. E-mail: bturkbey@yahoo.com

It is also important for the detection of local pelvic wall invasion and for accurate evaluation of distant metastasis in patients with invasive bladder carcinoma. A standard CT scan in conjunction with CT urography can be used to evaluate the entire urinary system in one step. The standard CT scan consists of unenhanced and postcontrast nephrographic phase images. CT urography includes excretory phase images. Precontrast images, which include the kidneys, ureters and bladder, are helpful to exclude the presence of urinary stones, which accounts for the most common etiology of hematuria. Postcontrast nephrographic phase images, covering the entire abdomen and pelvis, are obtained 70-90 seconds after the intravenous administration of iodinated contrast material (1.5-2 cc/kg at a rate of 34 ml/sec). On these images, bladder cancer can be seen as a papillary, sessile, infiltrating, mixed or flat lesion with contrast enhancement. Urothelial carcinomas enhance early and more intensely than normal bladder wall because of their increased vascularity; prior studies

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Fig. 2. â&#x20AC;&#x201D; Trans-abdominal ultrasound image of a male with bladder cancer shows a large infiltrating tumor lesion at posterior wall of bladder (arrows).

has shown that peak enhancement occurs approximately 60-80 seconds after contrast injection at a standardized dose and injection rate (dose: 2 ml/kg-maximum 160 ml-; injection rate: 4 ml/sec) (4). Urothelial carcinoma can be differentiated from blood clot, tissue debris and non-specific wall edema according to its contrast enhancement characteristics. Nephrographic phase images can also demonstrate abdominal and pelvic lympadenopathy, hepatic metastases, as well as incidental renal cortical masses. Tumor extension to periureteral and extravesical area can be differentiated depending on the high contrast interphase between the bladder and perivesical fat. The overall accuracy of MDCT and CT urography in detecting bladder cancer ranges from 89% to 97% in different studies (4-6). However, it is also known that the diagnostic value of parenchymal phase CT is limited for detecting lesions smaller than 1 cm with a reported sensitivity of 80%-83% (5). To avoid false positive diagnosis and pitfalls, the bladder must be optimally distended prior to the scan. Under-distension of the bladder increases the trabeculation of the wall, on the other hand over-distension may cause the underestimation of wall thickness and effacement of fat planes; both of these conditions can reduce the accuracy of CT. Excretory phase images are acquired when contrast material is excreted to the collecting tubules and the bladder is opacified with a delay time of approximately 710 minutes. Bladder tumors can be detected as a mass or plaque-like filling defects in an optimally distended

and homogenously opacified bladder. Instructing patient to take alternate prone and supine positions on the table or applying abdominal compression for optimum distention prior to scan are helpful maneuvers for obtaining a homogeneous contrast density in the bladder. In addition to conventional axial slices, multi-planar reformatted images facilitate the presentation of findings and may improve the performance of CT, specifically for tumors at the base and dome of the bladder. A single coronal image showing contrast filled collecting system and the bladder similar to intravenous urography technique can be achieved from axial excretory phase images using a maximum intensity projection algorithm. Excretory phase CT urography has been found to be comparable with IV urography for the evaluation of the urinary tract in patients with painless hematuria (7) (Fig. 3, 4). Additionally, early arterial phase images were reported to be useful in detection of renal pelvis and bladder malignancies (8). For local staging, CT cannot identify the depth of bladder wall invasion, but it can distinguish the perivesical fat infiltration, which indirectly depicts transmural tumor extension or stage T3b tumor and it should be remembered that transurethral tumor resection can lead to over-staging due to resultant focal wall thickening and perivesical fat stranding (9). Kim et al. reported an overall sensitivity and specificity of 89% and 95%, respectively, for the diagnosis of perivesical invasion on MDCT (4). If a time interval of 7 or more days between CT imaging and transurethral resection is provided,

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the sensitivity and specificity can improve to 92% and 98%, respectively. Currently, the diagnosis of nodal metastasis is based on CT morphologic and size criteria. Pelvic lymph nodes with a diameter greater than 10 mm in short axis and internal iliac and obturator lymph nodes greater than 8 mm are generally considered as metastatic (10). However, lymph nodes can enlarge secondary to a benign process and non-enlarged normal looking lymph nodes can contain microscopic metastases. Liver, bones and lungs are frequently involved in late stage metastatic disease (11). Urothelial carcinoma has propensity to be multicentric with multiple lesions in the bladder or with synchronous and metachronous lesions in the upper urinary system (9). CT urography is a good choice to scan the entire urinary system for the presence of multicentric lesions. Additionally, superficial bladder cancers, especially multifocal and high grade tumors, have a high propensity to recur and progress in grade and stage after treatment by transurethral resection (12). The standard follow-up procedure of these patients includes repeated conventional cystoscopy with biopsy to detect recurrence. Since the survival of the patient can be life-long, a minimal or non-invasive screening method would be a better choice. Virtual CT cystoscopy has become a promising method that can be used as a screening tool in the follow-up of these patients to reduce the number of repeated conventional cystoscopies. Up to date, it is mainly used for patients with contraindications for conventional method. CT cystography and virtual cystoscopy is performed by axial scanning of bladder after drainage of urine and distension of bladder with room air or carbon dioxide. The axial source data is reconstructed using surface rendering or volume rendering algorithm to obtain virtual cystoscopic images which allows real time three dimensional fly through examination of the bladder. The accuracy of CT cystoscopy for identifying masses greater than 5 mm in diameter was shown to be 100% and the accuracy for detecting neoplasm in these lesions was 95% (13). However, the reliability of virtual cystoscopy in detection and characterization of lesions smaller than 10 mm is inadequate. Recently, MDCT scanners promise better results in detection of small lesions due to improved spatial resolution.

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A Fig. 4. â&#x20AC;&#x201D; Contrast enhanced computed tomography of male admitted with hematuria demonstrates a tumor lesion localized at the left sided bladder diverticula (arrow).

C Fig. 3. â&#x20AC;&#x201D; Contrast enhanced computed tomography images at nephrographic (A) and urographic (B) phases demonstrate a papillary bladder cancer lesion at posterior wall of the bladder (arrows). Same lesion is also visualized at virtual CT cystography (C) (arrow).

Kim et al. reported a detection rate of 85% in lesions smaller than 10 mm using a 4-detector CT scanner (4). Tsampoulas et al., showed an overall sensitivity of 96% in detection of bladder cancer using a 16-detector CT (14). Virtual cystoscopy can also be performed by filling the bladder with contrast agent instead of air. Magnetic resonance imaging Magnetic resonance imaging has advantages over CT for staging

bladder neoplasm with its high soft tissue resolution, and direct multiplanar imaging capabilities. It has comparable results for detection of bladder carcinoma. A standard MRI protocol should include T1-weighted spin echo images of the entire pelvis, T2-weighted fast spin echo images of the bladder with a small field of view in at least two different planes, pre and post contrast dynamic T1-weighted images with fat suppression. For dynamic imaging, arterial and later phase images are

obtained with fast spoiled gradient echo sequences. Optimal distention of the bladder is crucial for diagnostic accuracy and this can be achieved by instructing the patient to not to void for at least 2 hours before the examination. T1-weighted images are helpful in detecting extravesical infiltration of bladder cancer, adjacent organ invasion (except prostate), pelvic lymphadenopathies and bone metastasis. Bladder wall and tumor demonstrate a low to intermediate signal intensity that is significantly different from high signal intensity of the perivesical fat and low signal intensity urine. T2-weighted images are mainly used to determine the depth of bladder wall invasion, presence of adjacent organ and pelvic side wall involvement. On T2weighted images, bladder tumors show intermediate signal intensity whereas; bladder wall and urine are characterized with low and high signal intensities, respectively. Dynamic contrast-enhanced images also delineate the presence and extent of muscle invasion and may differentiate tumor from fibrosis or edema. However, this distinction is still difficult to make shortly after transurethral resection. Bladder cancer enhances strongly and earlier than bladder wall on dynamic enhanced images. In staging, both T1- and T2-weighted images are helpful. Muscular layer invasion manifests as an interruption of the normal bladder wall signal intensity by the tumor signal. Presence of perivesical fat extension on T1- and T2-weighted images is consistent with a stage 3 disease (Fig. 5). The accuracy of MRI in the staging of bladder cancer and in detecting deep muscle invasion ranges from 62% to 85% and 82% to

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B Fig. 5. â&#x20AC;&#x201D; Coronal contrast enhanced T1W MR image of a male with microscopic hematuria demonstrates a focal enhancing thickening at right posterior wall of the bladder (A) (arrow). Same lesion is also visualized on axial T2 weighted MR cystography (B) and virtual MR cystoscopy (C) images (arrows).

C 96%, respectively (15-20). Overstaging has shown to be the most common error, which may be due to the presence of post-biopsy inflammation and edema. However, Tekes et al. concluded that the time interval was not affecting the accuracy of MRI in differentiating superficial and muscle invasive tumor (15). Metastatic lymph nodes have no specific signal intensity characteristics on both T1 and T2 weighted images; staging for nodal metastases relies on anatomic size and morphology criteria, similar to CT. With these criteria, microscopic metastasis in normal sized lymph nodes can easily be missed. Recently, IV administration of Ferumoxtran-10, which consists of ultra-small iron particles, has enabled better results in depicting nodal metastases even in normal sized lymph nodes. Deposition of

Ferumoxtran-10 in macrophages of normal lymph nodes causes signal loss on T2* weighted images. On the other hand, metastatic lymph nodes are characterized by high signal intensity since normal macrophages are replaced by tumor cells. Deserno et al. reported a significant improvement in nodal staging due to better depiction of metastases with the use of Ferumoxtran -10 in patients with bladder cancer (21). Distant metastasis can be screened by either MRI or CT, but MRI is superior for the evaluation of bone marrow metastasis. Similar to CT, virtual MR cystoscopy is also a potential alternative to conventional cystoscopy. However, one advantage of MR over CT is that it does not require radiation exposure and therefore, can be repeated more frequently as a screening tool. MR cystography can

be performed using either threedimensional (3D) T2-weighted fast spin echo sequence or 3D T1-weighted spoiled gradient echo sequence after achieving optimal distention and optimal contrast between the lumen and the bladder wall. For T2weighted imaging, there is no need for special preparation since normal high signal intensity of urine provides adequate contrast. Whereas; T1-weighted imaging requires bladder filling with gadolinium based contrast agent via a catheter or intravenous application to obtain adequate contrast. Alternatively, for obtaining non-contrast T1-weighted images, bladder can be distended by air similar to CT application. Virtual cystoscopy images are reconstructed from these volumetric dataset using same post-processing techniques with CT. The tumor detection rate of MR cystography and virtual MR cystoscopy ranges between 70% and 100% depending on the size of the tumor (22, 23). All studies agree that the accuracy of this technique is limited for tumors smaller than 5 mm in diameter, on the other hand, anterior bladder wall and intradiverticular lesions, which are challenging to detect via cystoscopy, can be more easily detected and better depicted on MR cystoscopy (24). Recently, El-Assmy and Matsuki examined the feasibility of diffusion

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weighted (DW) MRI in detection of bladder cancer. Initial results showed that bladder carcinomas had significantly lower apparent diffusion coefficient (ADC) values compared to surrounding tissues. Sensitivity and positive predictive values were 100% in both of those studies. These preliminary results promise the use of DW MRI in detection of bladder cancer. However, further studies are required to better understand the reliability of this technique (25, 26).

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Positron emission tomography (PET) Positron emission tomography (PET) has been increasingly utilized in Oncology.. While the routine clinical spatial resolution of PET imaging is limited (~ 4-6 mm), the ability to interrogate specific physiological processes, such as the rate of glucose and/or fatty acid metabolism, provides information which cannot be obtained with other anatomical imaging techniques. The most common tracer for PET imaging, 18F-fluoro-2-deoxy-2-D-glucose (18F-FDG) has been proved helpful in initial staging re-staging, and monitoring response to treatment in a wide variety of tumors. However, the main obstacle in the evaluation of bladder cancer is that the urinary excretion of18F-FDG interferes with the visualization of primary tumors and regional lymph nodes (Fig. 6) (27). In order to help overcome this limitation, Kamel et al. employed a method of diuretics and parenteral physiologic saline infusion in order to better evaluate abdominopelvic malignancies (28). In a study by Anjos et al., diuretics and oral hydration were use to remove excreted tracer in 17 patients, 11 of whom had not undergone cystectomy. 18F-FDG PET was able to detect bladder lesions in 6 of these 11 patients and 41% of patients were upstaged based on diuretic mediated 18F-FDG PET scans (29). There have been few reports on the utility of 18F-FDG PET in detection of distant metastases in bladder cancer (Fig. 7, 8). Kosuda et al. assessed the feasibility of 18F-FDG PET imaging in 12 patients with histologically proven bladder cancer. They were able demonstrate all sites of distant metastases and 2 of 3 nodal metastases (30). Heicappell et al. demonstrated the utility of 18FFDG PET in pretreatment evaluation of distant metastases in bladder cancer in a limited patient population of 8, 3 of whom had nodal

Fig. 6. â&#x20AC;&#x201D; Axial CT (A), PET (B), axial (C) and coronal (D) fused 18F-FDG PET-CT images of a male demonstrate a focus of increased radiotracer uptake at the anterior wall of the bladder consistent with bladder cancer (arrows).

metastases (31). More recently, in a study involving 47 evaluable patients, 18F-FDG PET/CT detected more malignant disease than conventional CT/MRI in 40% of patients and demonstrated overall sensitivity and specificity of 87% and 88% respectively. Moreover, the use of 18 F-FDG PET/CT changed management in 68% of patients (32). The limitations associated with urinary excretion of 18F-FDG have lead to attempts in investigation of different tracers that are not excreted in urine. Carbon-11 labeled choline (11Ccholine), which is not excreted by the kidneys, has been reported as a new PET agent for tumor detection and staging. Choline is an important component of the phospholipids in the cell membranes and elevated levels of choline and choline kinase can be found in malignant cells with high proliferation and increased cell membrane metabolism, all of which can result in increased 11C-choline uptake on PET. De jong et al. evaluated 5 healthy volunteers and 18 patients with bladder cancer with 11 C-choline PET. The tracer uptake of bladder wall was low in 5 healthy subjects and tumor foci were

demonstrated in 10 patients and lymph node metastases in 2 patients. Moreover, urinary tract radioactivity was absent in 27 of 28 subjects (33). Gofrit et al. used 11Ccholine PET in preoperative staging of 18 patients with 19 tumor regions and 11C-choline uptake was found to be increased in all cancer lesions. In 6 patients, uptake of 11C-choline in lymph nodes as small as 5 mm was visualized. Of these patients, 4 underwent surgery and histopathology confirmed malignancy in 3 of 4 (34). Picchio et al. compared diagnostic accuracies of contrast enhanced CT and 11C-choline PET in 27 patients with urothelial bladder cancer, and concluded that 11Ccholine PET is comparable to CT in residual disease detection, but superior to CT in lymph node metastases visualization (35). Recently, Yoshida et al. reported 11C-choline PET findings in 4 cases of bladder cancer. In one patient, a tumor focus was detected within the bladder with accompanying bone metastases, which was negative on bone scan. In the remaining 3 cases, intense accumulation of the tracer within the bladder hampered the 11C-choline

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Fig. 7. — Axial CT (A), PET (B), axial (C) and coronal (D) fused 18F-FDG PET-CT images of a male with bladder cancer (same patient in fig. 6) demonstrate a focus of increased radiotracer uptake at lower lobe of left lung consistent with metastases from bladder cancer (arrows).

PET evaluation and this accumulation was attributed to inflammatory and proliferative changes secondary to previous catheterizations (36). Amino acid transport and mechanism can be increased in cancer cells resulting in increased uptake of 11Cmethionine. Similar to 11C-choline, 11 C-methionine is not excreted in urine and can be used in detection of urinary tract malignancies by PET. Letocha et al. investigated the utility of 11C-methionine PET for diagnosis and treatment evaluation in 29 patients. In this study, the diagnostic accuracy of 11C-methionine PET was poor and the technique did not monitor the therapeutic effect of neoadjuvant chemotherapy (37). The same group evaluated the utility of 11 C-methionine PET in the diagnosis and staging of urinary bladder carcinoma in a cohort of 23 patients. Eighteen of 23 primary tumors were detected on 11C-methionine PET; moreover, tracer uptake levels were shown to be positively correlating with tumor stage (38). In regards to PET imaging of bladder cancer, 18F-FDG PET is useful for

detection of distant metastases, whereas its value is limited for detection of primary tumors or local recurrence. Though PET experience is limited with novel tracers such as 11 C-choline and 11C-methionine, may play a role in the detection of tumor lesions confined the bladder. Conclusion Bladder cancer is a common cancer type among men with propensity of multifocality and high recurrence rates. Imaging plays an important role in the early diagnosis and the staging of bladder cancer. Among current imaging modalities, ultrasound is used as a screening method for patients with hematuria, whereas CT and MR cystogram (with virtual applications) appear to be more accurate for lesion detection as well as for local staging. PET-CT with 18FFDG has limited role in diagnosis and local staging due to urinary excretion of the tracer, but it can be utilized for the depiction of distant metastases. Finally, early results of PET-CT applications with 11C-choline

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Fig. 8. — 62-year-old female with bladder cancer, status post cystectomy with ileal conduit. 18F-FDG PET-CT image shows hypermetabolic adenopathies in the paraaortic and bilateral common iliac regions (arrowheads), as well as in the left external iliac region (short arrows). There is an additional small node in the left supraclavicular region, which is suspicious for metastasis (arrow) (Image courtesy of Dr. Mark P. Dunphy from Memorial Sloan-Kettering Cancer Center, New York, NY, USA).

and 11C-methionine, which are not excreted through urine, can be more helpful for early diagnosis and local staging, but further research is required in this field. References 1. Jemal A., Siegel R., Ward E., Murray T., Xu J., Thun M.J.: Cancer statistics, 2007. CA Cancer J Clin, 2007, 57: 43-66. 2. Pavlica P., Gaudiano C., Barozzi L.: Sonography of the bladder. World J Urol, 2004, 22: 328-334. 3. Zhang J., Gerst S., Lefkowitz R.A., Bach A.: Imaging of bladder cancer. Radiol Clin North Am, 2007, 45: 183205. 4. Kim J.K., Park S.Y., Ahn H.J., Kim C.S., Cho K.S.: Bladder cancer: analysis of multi-detector row helical CT enhancement pattern and accuracy in tumor detection and perivesical staging. Radiology, 2004, 231: 725731.

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PROGNOSTIC VALUE OF VASCULARITY INDEX FOR THE DIAGNOSIS OF AUTOIMMUNE THYROID DISEASE I. Banaka1, G. Kaltsas1, St. Antoniou1, G. Kanakis1, A. Zilos1, C.S. Baltas2, D. Thomas1 Aim: to determine thyroid vascularity in healthy subjects and patients with autoimmune thyroid disease (AITD), and assess its sensitivity and specificity for the diagnosis of AITD. Methods: High-sensitivity color flow Doppler sonography (HSCFDS) was used to estimate the thyroid intraparenchymal vascularity in 31 euthyroid patients with Hashimoto’s thyroiditis (HD), 33 hypothyroid patients with HD, 13 hyperthyroid patients with Graves’ disease, and in 34 healthy controls. Images obtained from the ultrasound unit were further processed with a widespread, available imaging analysis program and the predictive value of the maximum vascularity index (VI) was used for further statistical analysis. Results: Compared to healthy controls, patients with AITD had higher mean VI of both the right and the left thyroid lobe (TL) (P < 0.001). The sensitivity of left TL VI values greater than 5.57% (the best cut-off value of the Receiver Operating Characteristics-ROC curve) for the diagnosis of AITD was 80.8% and the specificity was 85.3%. Right TL VI values greater than 14.75% had 84.6% sensitivity and 86.2% specificity for the differential diagnosis among patients with HT or GD. Conclusions: Measurement of right and left TL vascularity index using HSCFDS is a high specific tool, particularly where there is a high clinical suspicion of an autoimmune process. Key-words: Thyroid, US – Thyroiditis.

Color flow Doppler sonography (CFDS) has become an important non-invasive diagnostic method for the evaluation of thyroid vascularity and function (1). One of its main uses is the ability to distinguish hyperthyroidism from other low radioiodine uptake causes of thyrotoxicosis (1). In conditions related to hyperfunctioning thyroid gland such as Graves’ disease (2), toxic multinodular goiter (3) and autonomous adenoma (4) the vascular signals are increased, whereas they are decreased or normal in cases of thyrotoxicosis factitia (5), and destructive processes of thyroid gland, such as subacute thyroiditis or type-II amiodarone-induced thyrotoxicosis (6). Along with CFDS the echomorphological pattern is also used to verify the presence of autoimmunity due to a diffuse reduction in thyroid echogenecity (echointensity) and an irregular echo pattern often associated with this disorder (7, 8). Several qualitatively classifications of intrathyroidal vascular patterns distinctive to specific pathological entities have been proposed, with that of Vitti’s being the most widely used in clinical practice (9). This classification describes easily and quickly the intraparenchymal

thyroid blood flow, but remains highly subjective and is not sufficient enough to evaluate subtle variations of thyroid vascularity. Several techniques for semi-quantitative measurements of intrathyroidal blood flow have been applied for the differentiation of painless thyroiditis from Graves’ disease (10), and benign from malignant thyroid nodules (11). Similar techniques have been used for measurements of thyroid vascularity in healthy subjects (12), and in patients with subacute thyroiditis (13). Currently there are no available data regarding the predictive value of CFDS assessed thyroid vascularity for the diagnosis of autoimmune thyroid disease (AITD) per se and potential correlations with clinical or biochemical parameters. The main purpose of this study is to determine thyroid vascularity with a semi-quantitative, widespread available method in healthy subjects and in patients with AITD [Hashimoto’s thyroiditis (HT) and Graves’ disease (GD)], and to assess its sensitivity and specificity for the diagnosis of AITD and for the differential diagnosis between patients with HT and GD. Secondary goals are to correlate thyroid vascularity with clinical and biochemical indices

From: 1. Endocrine Unit, Department of Pathophysiology, National and Kapodistrian University of Athens, Athens, Greece, 2. Radiology Imaging Department, General Hospital of Athens “G. Gennimatas”, Athens, Greece. Address for correspondence: Dr D. Thomas, Endocrine Unit, Department of Pathophysiology, National and Kapodistrian University of Athens, Mikras Asias 75, 15575, Athens, Greece. E-mail: thomasproge@endo.gr

of thyroid autoimmunity, and to compare its sensitivity and specificity with other gray-scale sonographic findings. Materials and methods Subjects selection Between August 2008 and November 2009, a total of 1086 consecutive subjects from the outpatient clinic of the Department of Endocrinology and Metabolism, with unknown thyroid functional status, were screened. The study was approved by the local Bioethical Committee and informed consent was obtained from all participants. All subjects included in the study underwent a detailed physical examination, and a complete medical and family history was recorded. From these subjects, 616 were excluded due to acute or chronic underlying diseases and co-morbidities and/or residence in iodine-deficient areas. All remaining 470 subjects from the same iodine-replete area, Athens and its suburbs (14, 15), were further evaluated with thyroid sonography and with free triiodothyronine (fT3), free thyroxine (fT4), thyrotropin (TSH), thyroglobulin (anti-Tg) and thyroid peroxidase (anti-TPO) autoantibodies, and thyroid stimulating hormone receptor antibodies (TRAb) levels measurements; when indicated, thyroid scintigraphy was performed. Although we did not include food questionnaire in the study participants, all subjects used commercial iodized salt. Subjects with simple goiter, non-autoimmune

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Table I. — Epidemiological characteristics and laboratory findings of the patients, at the start of the study.

n Age (years) (sd) Sex (Female/Male) BMI (sd) TSH (µU/ml) (sd) Anti-Tg positive (%) Anti-TPO positive (%) TSI positive (%) Mean thyroid volume (cc) (range)

Control group

AITD type-1

AITD type-2

AITD type-3A

41.3 (17.7) 25/9b 25.65 (3.63) 2.12 (0.94) 0 0 0 8.8 (3.5-19.8)

44.5 (13.1) 26/5b 25.85 (4.09)c 2.37 (0.9) 51.61 90.3 0 11 (5.3-19.1) a

40.4 (13.1) 29/4b 25.76 (3.94)c 11.84 (22.76) 54.54 93.9 0 11.8 (1.02-33.3) a

41.3 (12.4)a 10/3b 25.18 (3.44)c 0.025 (0.037) 53.84 69.23 69.23 20.7 (5.4-73.1)

statistically non-significant from controls (Kruskal-Wallis non-parametric analysis of variance, p = 0.703 and analysis of variance-AN.O.VA., p = 0.96 respectively). b statistically non-significant from controls (Chi-square test, p = 0.464). AITD: autoimmune thyroid disease. a,c

thyroiditis, non-autoimmune hyperthyroidism, and thyroid nodular disease, were further excluded. Finally 77 patients, all of Greek ethnic origin, with high levels of anti-Tg and/or anti-TPO and/or TSI due to autoimmune thyroid disease (AITD) were selected for further studies. The 77 patients were categorized further into 3 groups: clinically euthyroid patients with Hashimoto’s thyroiditis (AITD type-1) (n = 31) and TSH between normal ranges (0.274.2 µU/ml), hypothyroid patients with Hashimoto’s thyroiditis (AITD type-2) (n = 33), with TSH levels greater than 4.22 µU/ml, with or without clinical symptoms of hypothyroidism consistent with hypothyroidism, and patients with clinically and biochemically (TSH levels less than 0.1 µU/ml) Graves’ disease (AITD type-3A) (n = 13). The epidemiological and laboratory parameters of the 77 patients are shown in (Table I). An age and sex-matched group (Table I) of 34 healthy Greek volunteers, without any previous medical or family history of thyroid disease or any other acute or chronic diseases were selected for comparisons. All asymptomatic controls were from the same iodine replete area of Athens, and had the same hormonal and sonographic investigations as the patient’s group.

anti-Tg and/or anti-TPO titers that were confirmed in a second test were classified within the AITD group. TRAbs were measured using commercial kit (Diasorin Inc., Stillwater, MN, USA, cut-off value: 10%). Thyroid stimulating hormone (TSH) levels were measured using a one step sandwich assay (RIAgnosthTSH: CIS Bio International, Gif-Sur-Yvette, Cedex, France, normal range: 0.25-4 mU/l). Free triiodothyronine and fT4 levels were measured by electrochemiluminescence immunoassay (E170 analyzer, Roche, Diagnostics, Mannheim, Germany), with reference values 3.96.9 pmol/l and 11-23 pmol/l respectively. Following the diagnosis, all patients with AITD type-2 were treated with levo-thyroxine, with target serum TSH values in the normal or low-normal range (1.47 ± 0.34 µU/ml). Patients with AITD type3 were initially treated with adequate doses of antithyroid drugs until euthyroidism was obtained and maintained with titration of the antithyroid drug dosage; only three patients were treated with a block (methimazole) and replace (levo-thyoxine) regimen. Control subjects and patients with AITD type-1 were regularly followed up at six-month intervals with physical examination, endocrine testing, and thyroid ultrasonography.

Study protocol Anti-Tg and anti-TPO autoantibodies were measured in the same laboratory using a two-site immunoluminometric assay (Diasorin, LIASON analyzer, normal range: < 100 IU/ml and < 25 IU/ml respectively). Only individuals with high

Thyroid ultrasonography Thyroid ultrasonography was carried out using a high-resolution apparatus (Logic-Book XP, General Electric Co, USA) equipped with a 611 MHz broadband linear array probe. A single operator who was

unaware of the diagnosis performed the scans. Patients were examined by gray-scale and color Doppler examination in supine position, with the neck in hyperextension. Although all participants underwent a second and a third thyroid sonogram six and twelve months later respectively, only the measurements of the first examination were used for the purpose of the study. In gray-scale ultrasonography, the maximum diameter of the longaxis and depth were estimated in longitudinal plane, while short-axis in transverse images. The maximum volume (cm3) of each lobe was calculated using the approximate formula of the ellipsoid π/6 x [length (cm)] x [width (cm)] x [depth (cm)] (16). Measurements of thyroid volume, echogenecity and echostructure were made by grayscale histogram analysis (17). Following sonographic evaluation of the thyroid echogenecity, all the participants were categorized into two groups: with normal or reduced (from slightly reduced-grainy echo texture to levels below that of echoes coming from muscles) echo intensity. Furthermore, all the participants were categorized into two groups: with homogeneous or irregular echo pattern of the thyroid gland. High-sensitivity color flow Doppler sonography was used to estimate the intraparenchymal blood flow pattern. Normally, the vascularity of the thyroid tissue itself was minimal. Pulse repetition frequency was adjusted to 2.3 KHz, wall filters to 102 Hz, and Doppler frequency to 5 MHz. We tried to adjust the noise by initially increasing the color gain to a level that showed noise, and

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Table II. — Predictive value of vascularity index, reduced echogenecity and irregular echo pattern for the diagnosis of autoimmune thyroid disease. Sensitivity (%)

Specificity (%)

Sensitivity X Specificity

Youden index*

Positive predictive value (%)

Negative predictive value (%)

71.8 80.8 75.32 88.31

91.2 85.3 82.35 67.64

0.6548 0.6892 0.62 0.597

0.63 0.66 -

96.49 92.53 90.6 86.08

59.25 65.9 59.57 71.87

right TL VI > 7.44% left TL VI > 5.57% reduced echogenecity irregular echo pattern *sensitivity + specificity-1.

Fig. 1. — A: Transverse section of the left thyroid lobe (LL), as shown in color flow Doppler sonogram. I: isthmus, T: trachea, E: esophagus, C: left carotid artery, J: left jugular vein. Panel B: the boundaries of the left thyroid lobe were manually outlined and the number of pixels was counted by the program (ALL = 75760 pixels). Panel C: the boundaries of all vessels spots were manually outlined, the number of colour pixels of each spot (A1 = 788 pixels, A2 = 400 pixels, A3 = 340 pixels, A4 = 153 pixels) was counted by the program and the total number of colour pixels were calculated as following: Avessels = A1+A2+A3+A4 = 1681pixels. Vascularity index (VI) was further calculated by dividing the number of colour pixels of vessels spots (Avessels) to the left lobe pixels (ALL): VI = Avessels/ALL = 0.0222 or 2.22%.

then decreasing until the noise disappeared. Because of variations in arterial flow during the cardiac cycle, and the number and size of vessels that appear on static images multiple sampling of at least 6 sections of each thyroid lobe (TL) was performed and the section with the maximum vascularity was used for further analysis. For the evaluation of thyroid vascularity, images from each TL were retrieved from the ultrasound unit and converted into high-resolution tagged image file format (TIFF). All images were further processed with a widespread, available for downloading from public domain, imaging analysis program (ImageJ, 1.42q, N.I.H., USA, http://rsd.info.nih.gov/ij). The vascularity index (VI = total pixels of vessels spots of the lobe/total image pixels of the lobex100 %) was calculated for all images of each TL (Fig. 1) and the highest VI (%) was used for statistical analysis. Thyroid echo-

genicity was also measured with histogram analysis, using the same program and the same technique. Tissue echo levels were automatically calibrated to the value of 255 for the white pixels and 0 for the black pixels. The mean echo level of all pixels of the parenchyma of each thyroid lobe and of the ipsilateral strap muscle was counted and the hypogenecity index (HI) was calculated, according to the formula: HI = mean echo level of all pixels of strap muscle/mean echo level of thyroid lobe. Conventionally, we considered that hypogenecity was present if only HI was greater than 1. The time needed for imaging processing and for quantifying the vascularity of each thyroid lobe was 10-20 minutes. Statistical analysis Paired t-test was used to compare mean VI (%) of the right and the left thyroid lobe, in controls, patients

with AITD type-1, 2, and 3. Following the application of Levene’s test for homogeneity of variances, non-parametric analysis of variance (KruskalWallis one way AN.O.VA) was used to compare VI (%) among controls and patients with AITD type-1, 2, and 3, and among controls and seropositive patients for anti-TPO or anti-Tg and seropositive patients for both anti-TPO and anti-Tg. The same statistical test was used to compare the mean age among controls and patients with AITD type-1, type-2 and type-3. Post hoc comparisons were made using Mann-Whitney U test with a downward adjustment of the level to compensate for multiple comparisons. Spearman’s (rs) correlation coefficient was calculated for the correlation of VI (%) with age, Basic Metabolic Index (BMI), TSH levels, hypogenecity index (HI), and total volume of thyroid gland among control subjects and patients with AITD type-1, 2, and 3. Chi-square test and parametric analysis of variance

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were used to compare the females/males ratio and mean basic metabolic index (BMI) between healthy controls and patients with AITD type-1, type-2 and type-3. Receiver operating characteristic (ROC) curve for VI (%) (a plot of the sensitivity of VI or true positive rate to the false negative rate) was developed as a means for pretest probability of AITD. The best cut-off value of the ROC plot was determined to maximize the Youden index (sensitivity+specificity-1). Calculations were performed using the Number Cruncher Statistical System (NCSS/PASS 2000, Dawson Edition) and Statistical Software for Social Sciences (SPSS, v.13.0). p < 0.05 was considered statistically significant. Results No statistically significant differences were observed in mean VI (%) of the right and the left TL among controls (3.86 ± 3.91 vs 3.78 ± 3.4, P = 0.844), patients with AITD type-1 (9.58 ± 5.86 vs 10.26 ± 7.43, P = 0.5), patients with AITD type-2 (13.4 ± 13.49 vs 14.03 ± 16.42, P = 0.657), and patients with AITD type-3 (32.53 ± 15.45 vs 30.73 ± 14.27, P = 0.673). Patients with AITD type-1, AITD type2, and AITD type-3 exhibited higher mean VI (%) measurements of both the right and the left TL compared to controls (8.22 ± 5.78, 13.49 ± 12.75, 26.42 ± 15.45, 3.63 ± 3.84, P < 0.001, and 9.49 ± 6.87, 13.8 ± 14.74, 24.67 ± 14.27, 3.45 ± 3.54, P < 0.001, respectively). In patients with AITD, the area under the ROC curves for VI (%) of the right TL and left TL was 0.843 (P < 0.001) and 0.862 (P < 0.001) respectively. The best cut-off value of the ROC plot for the right and left TL VI was 7.44% and 5.57% respectively. The sensitivity and specificity for the diagnosis of AITD of right TL VI values greater than 7.44% were 71.8% and 91.2% respectively (point A, Fig. 2), whereas those of left TL VI values greater than 5.57% were 80.8% and 85.3% (point B, Fig. 2) respectively. For the differential diagnosis among patients with HT or GD, right TL VI (%) values greater than 14.75% (Youden index = 0.708) had 84.6% sensitivity and 86.2% specificity, while left TL VI (%) values greater than 16.8% (Youden index = 0.615) had 76.9% sensitivity and 84.6% specificity. Compared to reduced echogenecity and irregular echo pattern, right TL VI values greater than 7.44% were more specific, but less sensitive for the diagnosis of AITD

Fig. 2. — Receiver operating characteristic (ROC) curves for vascularity index of both right and left thyroid lobe showing the pretest probability of autoimmune thyroid disease.

(Table II). Right and left TL VI was positively and significantly correlated with right and left HI (rs = 0.225, p = 0.016 and rs = 0.302, p < 0.001, respectively). Twenty-seven out of 31 euthyroid patients with Hashimoto’s thyroiditis had increased right TL VI (> 5.57%) and 62.9% of them had right TL hypogenecity (HI > 1). Twenty-two out of 33 hypothyroid patients with Hashimoto’s thyroiditis had increased right TL VI and 31.8% of them had right TL hypogenecity. All patients with Graves’ disease had increased right TL VI, but only 23% of them had right TL HI > 1. Statistically significant correlations were also found between right TL VI (%) and age (rs = -0.22, p = 0.02), BMI (rs = -0.207, p = 0.029), total thyroid volume (rs = 0.257, p = 0.006), and between left TL VI (%) and age (rs = -0.185, p = 0.05), BMI (rs = 0.225, p = 0.017), and total thyroid volume (rs = 0.278, p = 0.003).

The mean right TL VI (%) of controls was lower compared to patients who had only anti-TPO or anti-Tg, and those who had both anti-TPO and anti-Tg (3.63 ± 3.84, 13.26 ± 13.04, 13.91 ± 12.26, P < 0.001). Similarly, mean left TL VI (%) of controls was lower compared to patients who had only anti-TPO or anti-Tg, and those who had both anti-TPO and anti-Tg (3.45 ± 3.54, 14.07 ± 14.08, 13.68 ± 11.8, P < 0.001). No statistically significant differences in mean right TL VI (%) and left TL VI (%) were observed among patients who had both anti-TPO and anti-Tg, and patients who had antiTPO or anti-Tg (p = 0.587 and p = 0.727, respectively). Discussion The findings of the present study suggest that left TL VI values greater than 5.57% exhibit 80.8% sensitivity

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for the diagnosis of AITD whereas the sonographic appearance of autoimmune thyroiditis may vary, reflecting the phase and the severity of the disease process. For example, a diffuse hypoechoic pattern in a patient with lymphocytic thyroiditis has been shown to correlate with the replacement of the gland by lymphocytes and is highly predictive of either the existence or the future development of hypothyroidism (18). We calculated ROC curves for the mean VI (VI of right lobe+VI of left lobe/2, data not shown), but the Younden index was not as high as that of the left lobe. Thus, VI of the left lobe seems to be the best predictor of autoimmune thyroid disease in our study. The false negative values of VI could be attributed to the normal sonographic appearance of the thyroid gland in some patients, especially at early stages of AITD. Although the thyroid autoimmune process has already begun, thyroid tissue and vascularity may remain intact and thyroid echostracture changes may not be typical for AITD. It has been shown that sonographic appearance of thyroid gland may remain normal, even for 46 months following the diagnosis of Hashimoto’s thyroiditis in children (19). Although similar data are not available for adult populations, it is probable that the 12-month follow-up period used in our protocol may be too short for the increased thyroid vascularity to become evident in some of the patients. Another reason for the low VI values in some of our patients could be the lack of hypervascularity found in patients with the atrophic form of thyroiditis (20). However, only a small proportion of the negative findings observed could be attributed to thyroid gland atrophy. Only one patient (1.3%) had heterogeneous and atrophic thyroid parenchyma, profound hypoechoic pattern, and coarse septations from fibrous band all consisting thyroid sonographic findings encountered in the atrophic form of thyroiditis (20). A further potential reason for a relatively low sensitivity of the VI in identifying AITD could be the inclusion of patients that have been receiving replacement therapy with levothyroxine. In order to avoid this confounding factor we have not included such patients in the studied population, because we had already observed that patients receiving levothyroxine for some years had lower mean values of VI, almost as low as healthy controls.

Our findings showed that right TL VI values greater than 7.44% have 91.2% specificity for the diagnosis of AITD. We observed that 3 out of the 34 healthy controls studied had VI (%) values greater than 7.44%, without any other sonographic findings suggestive of AITD and normal titres of thyroid autoantibodies. Although none of these subjects presented with any clinical or laboratory findings of AITD and still remain diseasefree, seronegative thyroiditis could only be excluded if the follow-up period was longer (21). The possibility of increased VI (%) values in such subjects being an early sign of autoimmune thyroiditis remains hypothetical and needs to be addressed in a formal comparative prospective study. For our 34 healthy controls we found an overall mean VI equal to 3.55 %, similar to 3.67% found by Macedo TAA et al. in 84 healthy subjects (22). Increased vascularity in thyroid sonography could be diagnosed in patients with TSH secreting pituitary adenomas or resistance to thyroid hormone (23), acromegaly (24), and pregnancy (25); however patients with such diseases were initially excluded and no related signs, symptoms or typical laboratory findings were detected in any of our healthy controls or any of the patients at the start or during the study. Although right TL VI values greater than 14.75% were sensitive and specific enough to differentiate patients with Graves’ disease from those with Hashimoto’s thyroiditis, in clinical practice we encountered a few difficulties. The two disorders are related in fundamental ways, as it has been proposed that GD develops on a background of thyroiditis. The progression from Graves’ hyperthyroidism to chronic autoimmune thyroiditis and hypothyroidism is well-recognized (26) and the converse also occurs (27). Moreover, there are patients who have hypothyroidism one year, Graves' hyperthyroidism another, and hypothyroidism again later (28). Finally, ultrasonographic conversion from end-stage HD to Graves’ hyperthyroidism may take some time to become evident, 30 months in a previously described patient (29). The follow-up period of our study was much shorter and in our opinion the VI at the time of diagnosis cannot provide further information for the conversion from one autoimmune disease to the other. We compared the sensitivity and specificity of VI (%) to the correspon-

189

ding of reduced echogenicity and irregular echo pattern and found the first to be more specific, but less sensitive for the diagnosis of AITD. The validity of using reduced thyroid echogenicity as a predictor of possible AITD in general has been found to be very good (18, 30). Pedersen OM et al. studied 452 patients and found the positive and negative predictive values of reduced thyroid echogenicity as an indicator of AITD to be 88.3% and 93%, respectively (31). Despite this, they found a higher rate of false negative values and they concluded that some patients presented with less severe markers of autoimmune process may have not evolve the typical sonographic findings. However, reduced thyroid echogenecity still remains one of the principal findings of AITD. We also observed that 88.3% of patients with AITD had irregular echo pattern, another important marker for early thyroid failure. The prognostic value of the evaluation of echogenecity and echo pattern has been found to be increased in the general population, as only a small minority of randomly selected subjects has increased levels of thyroid autoantibodies, when both sonographic characteristics are absent (32). We also found similar VI (%) values in patients seropositive for both anti-TPO and anti-Tg, as compared to seropositive patients for anti-TPO or anti-Tg. Given that high levels of both anti-Tg and anti-TPO are closely related to autoimmune process and the development of goiter and hypothyroidism (21, 33), it could be proposed that seropositivity for both thyroid peroxidase and thyroglobulin autoantibodies represents a mechanism affecting mainly the gray-scale sonographic appearance and in a lesser extend the density of thyroid vessels in a sonographic section. The former was also supported by Vlachopapdopoulou et al, who observed that double seropositivity was associated with an acceleration of the time needed for the thyroid sonographic findings to change and become diagnostic for Hashimoto’s thyroiditis (19). In this study we used a semiquantitative method for the evaluation of thyroid vascularity. Vascularity index represents the total area of vessels spots in each section of the thyroid lobe, but is not currently being used for the direct measurement of thyroid blood supply. Although the time needed for imaging processing and for

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quantifying the vascularity of each thyroid lobe relatively short, an automated system would be more helpful in clinical practice. Nowadays, most of the high resolution apparatus have their own system for the measurements of the VI; however we preferred to use a wide spread available software for convenient reasons. In conclusion, measurement of vascularity index is an easy, noninvasive, and reproducible method. Although it depends on operator experience, it can provide relatively prompt information on thyroid status and diagnose autoimmune thyroid disease with high specificity albeit relatively low sensitivity. References 1. Bogazzi F., Bartalena L., Brogioni S., et al.: Thyroid vascularity and blood flow are not dependent on serum thyroid hormone levels: studies in vivo by color flow Doppler sonography. Eur J Endocrinol, 1999, 140: 452-456. 2. Baldini M., Castagnone D., Rivolta R., Meroni L., Pappalettera M., Cantalamessa L.: Thyroid vascularization by color Doppler ultsasonography in GD disease. Changes related to different phases and to the longterm outcome of the diasease. Thyroid, 1997, 7: 823-828. 3. Boi F., Loy M., Piga M., Serra A., Atzeni F., Mariotti S.: The usefulness of conventional and echo Doppler sonography in the differential diagnosis of toxic multinodular goiters. Eur J Endocrinol, 2000, 143: 339-346. 4. Becker D., Bair HJ., Becker W., et al.: Thyroid autonomy with color-coded image-directed sonography: internal hypervascularization for the recognition of autonomous adenomas. J Clin Ultrasound, 1997, 25: 63-69. 5. Bogazzi F., Bartalena L., Vitti P., Rago T., Brogioni S., Martino E.: Color flow Doppler sonography in thyrotoxicosis factitia. J Endocrinol Invest, 1996, 19: 603-606. 6. Bogazzi F., Bartalena L., Brogioni S., et al.: Color flow Doppler sonogaphy rapidly differentiates type I and type II amiodarone-induced thyrotoxicosis. Thyroid, 1997, 7: 541-545. 7. Nordmeyer J.P., Shafeh T.A., Heckmann C.: Thyroid sonography in autoimmune thyroiditis. A prospective study on 123 patients. Acta Endocrinol (Copenh), 1990, 122: 391395. 8. Vitti P., Rago T., Mancusi F., et al.: Thyroid hypoechogenic pattern at ultrasonography as a tool for predicting recurrence of hyperthyroidism after medical treatment in patients with Graves’ disease. Acta Endocrinol, 1992, 126: 128-131.

JBR–BTR, 2011, 94 (4) 9. Vitti P., Rago T., Mazzeo S., et al.: Thyroid blood flow evaluation by color-flow Doppler sonography distinguishes Graves’ disease from Hashimoto’s thyroiditis. J Endocrinol Invest, 1995, 18: 857-861. 10. Ota H., Amino N., Morita S., et al.: Quantitative measurement of thyroid blood flow for differentiation of painless thyroiditis from Graves’ disease. Clin Endocrinol, 2007, 67: 41-45. 11. Lyshchik A., Moses R., Barnes S.L., et al.: Quantitative analysis of tumor vascularity in benign and malignant solid thyroid nodules. J Ultras Med, 2007, 26: 837-846. 12. Ying M., Douglas K.S., Yung D.M.C., Lee E.S.T.: A semi-quantitative approach to compare high-sensitivity power Doppler sonography and conventional power Doppler sonography in the assessment of thyroid vascularity. Thyroid, 2009, 19: 1265-1269. 13. Hiromatsu Y., Ishibashi M., Miyake I., et al.: Doppler ultrasonography in patients with subacute thyroiditis. Thyroid, 1999, 9: 1189-1193. 14. Doufas G., Mastorakos G., Chatziioannou S., et al.: The predominant form of non-toxic goiter in Greece is now autoimmune thyroiditis. Eur J Endocrinol, 1999, 140: 505511. 15. Koutras D.A., Alevizaki M., Tsatsoulis A., Vagenakis A.G.: Greece is iodine sufficient. Lancet, 2003, 2: 405-406. 16. Murakami Y., Takamatsu J., Sakane S., Kuma K., Ohsawa N.: Changes in thyroid volume in response to radioactive iodine for Graves’ hyperthyroidism correlated with activity of thyroid-stimulating antibody and treatment outcome. J Clin Endocrinol Metab, 1996, 81: 3257-3260. 17. Schiemann U., Avenhaus W., Gellner R., Gross M.: Standardized grey-scale ultrasonography in Hashimoto’s thyroiditis: correlation of hypoechogenicity values to autoimmune activity. Eur J Endocrinol, 2002, 15: 46-47. 18. Marcocci C., Vitti P., Cetani F., Catalano F., Concetti R., Pinchera A.: Thyroid ultrasonography helps to identify patients with diffuse lymphocytic thyroiditis who are prone to develop hypothyroidism. J Clin Endocrinol Metab, 1991, 72: 209-213. 19. Vlachopapadopoulou E., Thomas D., Karachaliou F., et al.: Evolution of sonographic appearance of the thyroid gland in children with Hashimoto’s thyroiditis. J Pediatr Endocrinol Metab, 2009, 22: 339344. 20. Vitti P., Lampis M., Piga M., et al.: Diagnostic usefulness of thyroid ultrasonography in atrophic thyroiditis. J Clin Ultrasound, 1994, 22: 375379. 21. Vanderpump M.P.J., Tunbridge W.M.G., French J.M., et al.: The incidence of thyroid disorders in the community: a twenty-year follow-up of the

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Whickham Survey. Clin Endocrinol, 1995, 43: 55-68. Macedo T.A.A., Chammas M.C., Jorge P.T., et al.: Reference values for Doppler ultrasound parameters of the thyroid in a healthy iodine-nondeficient population. Brit J Radiol, 2007, 80: 625-630. Bogazzi F., Manetti A.L., Tomisti L., et al.: Thyroid color flow Doppler sonography: an adjunctive tool for differentiating patients with inappropriate thyrotropin (TSH) secretion due to TSH-secreting pituitary adenoma or resistance to thyroid hormone. Thyroid, 2006, 16: 989-995. Bogazzi F., Manetti L., Bartalena L., et al.: Thyroid vascularity in patients with active acromegaly. Clin Endocrinol (Oxf), 2002, 57: 65-70. Hari Kumar K.V., Vamsikrishna P., Verma A., Muthukrishnan J., Meena U., Modi K.D.: Evaluation of thyrotoxicosis during pregnancy with color flow Doppler sonography. Int J Gynecol Obstet, 2008, 102: 152-155. Tamai H., Kasagi K., Takaichi Y., et al.: Development of spontaneous hypothyroidism in patients with Graves' disease treated with antithyroidal drugs: clinical, immunological, and histological findings in 26 patients. J Clin Endocrinol Metab, 1989, 69: 4953. Takasu N., Yamada T., Sato A., et al.: Graves' disease following hypothyroidism due to Hashimoto's disease: studies of eight cases. Clin Endocrinol (Oxf), 1990, 33: 687-698. Kraiem Z., Baron E., Kahana L., Sadeh O., Sheinfeld M.: Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism. Clin Endocrinol (Oxf), 1992, 36: 211-214. Champion B., Gopinath B., Ma G., El-Kaissi S., Wall J.R.: Conversion to Graves’ hyperthyroidism in a patient with hypothyroidism due to Hashimot’s thyroiditis documented by real-time ultrasonography. Thyroid, 2008, 18: 1135-1137. Sostre S., Reyes M.M.: Sonographic diagnosis and grading of Hashimoto’s thyroiditis. J Endocrinol Invest, 1991, 14: 115-121. Pedersen O.M., Aardal N.P., Larssen T.B., Varhaug J.E., Myking O., Vik-Mo H.: The value of ultrasonography in predicting autoimmune thyroid disease. Thyroid, 2000, 10: 251-259. Vejbjerg P., Knudsen N., Perrild H., et al.: The association between hypogenecity or irregular echo pattern at thyroid ultrasonography and thyroid function in the general population. Eur J Endocrinol, 2006, 155: 547-552. Gordin A., Lamberg B.A.: Spontaneous hypothyroidism in symptomless autoimmune thyroiditis: a long term follow-up study. Clin Endocrinol (Oxf), 1981, 15: 537-543.

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CT-GUIDED PERCUTANEOUS DRAINAGE OF LUNG ABSCESSES: REVIEW OF 40 CASES M. Kelogrigoris, P. Tsagouli, K. Stathopoulos, I. Tsagaridou, L. Thanos1 Purpose: To evaluate the safety and effectiveness of CT-guided percutaneous drainage of lung abscesses considering success rate versus complications. Methods: This retrospective study was carried out at Computed Tomography and Interventional Radiology Department of Sotiria Hospital , Athens, Greece, from 1/1/2007 to 1/1/2010. Forty patients with lung abscesses in which antibiotic therapy failed and were managed with CT-guided percutaneous drainage were included in the study. Catheter placement was carried out using Trocar technique in the majority of the cases. Results: Lung abscess completely resolved with no residual cavity in thirty three patients. Seven patients had residual cavity and surgery was performed. Thus, the success rate of radiological drainage of the lung abscesses (33/40) was 83%. Five (13%) patients developed pneumothorax. Three developed moderate pneumothorax and chest-tube needed to be inserted and two patients developed mild pneumothorax which was managed with aspiration. These patients were kept under observation and followed-up by chest X-rays. No other complications and no mortality occurred during the procedure for all the forty patients. Conclusion: CT-guided percutaneous catheter drainage is a useful and safe procedure for the treatment of patients with lung abscesses who do not respond to medical therapy and should be considered a valuable alternative to open surgery. Key words: Lung abscesses â&#x20AC;&#x201C; Abscess, percutaneous drainage.

Lung abscess is defined as a localized area of liquefactive necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection (1). Although 80-90% of pyogenic lung abscesses are now successfully treated with antibiotics (2), occasionally this conservative therapy may fail (3-5), which could be due to the virulence of the responsible pathogens or failure to achieve an adequate concentration of antibiotics within the abscess cavity (2, 6, 7). Severe underlying lung disease and decreased lung compliance may play a role in the failure of an abscess cavity to drain spontaneously and hence failure of medical therapy (2, 6). Image guided percutaneous catheter drainage of intrapulmonary air and fluid collections is an alternative treatment option with less morbidity and mortality than surgical resection of intrapulmonary lung abscess of those patients who do not respond to medical therapy. The use of CT allows optimal characterization of intrapulmonary collection, optimal catheter placement and enables safe and effective evacuation. The purpose of the present retrospective study was to evaluate the results of CT-guided percutaneous

drainage for lung abscesses in a hospital of chest diseases (Sotiria General Hospital of Chest Diseases, Athens, Greece) over a period of 36 months. Patients and methods The medical and radiological files of all patients with lung abscesses who underwent percutaneous drainage under CT guidance from 1/1/2007 to 1/1/2010 at Computed Tomography and Interventional Radiology Department of Sotiria Hospital of Chest Diseases, Athens, Greece were reviewed. The study was approved by the appropriate ethical committees related to the hospital and all the forty patients that were included in it gave informed consent to the work. Twenty eight patients had lung abscesses due to bacterial pneumonia and twelve due to tuberculosis (TB) and all were diagnosed by computed tomography with intravenous contrast media. Maximum transverse diameter of the abscess was 4-6 cm in 13 patients, 6-8 cm in 16 patients and bigger than 10 cm in 11 patients. Ten patients had abscess at right upper lobe, twelve patients at right lower lobe, seven patients at left upper lobe and eleven patients at left

From: 1. Computed Tomography and Interventional Radiology Department, Sotiria Chest Diseases Hospital, Athens, Greece. Address for correspondence: Dr M. Kelogrigoris, M.D., Lamias 24, G-11523, Ampelokipoi, Athens, Greece. E-mail: kelogre.mic@hotmail.com

lower lobe. In thirty three patients, abscess was peripherally located adjacent to pleura and in the rest deeply placed with intervening lung in between. All procedures used pigtail catheter chest tubes (8F to 12 F).The size of the catheter depended on the maximum transverse diameter of the abscesses. A direct trocar method was usually used for tube insertion , after the puncture site was sterilely prepared and anesthetized; however, a modified Seldinger technique was also used in some cases when there was difficulty for the accurate placement of the catheter. For the modified Seldinger, once the puncture site was sterilely prepared and anesthetized, 18-gauge lumbar puncture needle was placed through the chest wall into the abscess cavity and aspiration of pus confirmed the adequate positioning of the needle. A 0.035 guide wire was then introduced through the needle. Serial dilation and pigtail catheter insertion were performed using the guide wire. The catheter was secured in the place by suturing (8) and was connected to a continuous suction drainage system (minus 20 cm of water). Flushing the tube with 15 ml of sterile saline three times daily was usually prescribed to assure patency of the tube. It has to be mentioned that complete evacuation by aspiration of the abscess cavity was not performed on CT table because it can result in severe hemoptysis. After the procedure, repeated CT images were taken to confirm the correct catheter placement. Day-to-

M W M W M W M M M M W M M M W M M M M M M W M M M M W W M M M M W M M M M M W M

SEX LUL RLL LLL RUL RLL RUL LLL LLL RLL RUL LUL LLL RUL RLL LLL RUL LUL LLL RLL RLL RLL LUL RUL RLL LUL RUL LLL RUL RLL LLL RLL LUL RLL RLL LLL LLL LUL RUL LLL RUL

LOBE

RUL = Right Upper Lobe RLL = Right Lower Lobe LUL = Left Upper Lobe LLL = Left Lower Lobe

64 26 51 44 59 77 70 58 60 49 50 88 76 79 57 37 45 64 70 66 61 42 47 79 48 52 56 66 56 60 65 67 72 81 59 58 67 77 73 64

AGE(years)

F = French S = Seldinger

<8 > 10 <8 <8 <8 <8 <8 > 10 <6 <6 <8 <8 <6 <8 <8 <6 <6 <8 <8 > 10 > 10 <8 <8 <8 <6 <6 > 10 <6 > 10 <6 > 10 <6 > 10 <6 > 10 > 10 <6 <8 > 10 <6

SIZE (cm) 10F 12F 10F 10F 10F 10F 10F 12F 8F (S) 8F (S) 10F 10F 8F 10F 10F 8F 8F (S) 10F 10F 12F 12F 10F 10F 10F 8F (S) 8F 12F 8F 12F 8F 12F 8F (S) 12F 8F 12F 12F 8F (S) 10F 12F 8F (S)

CATHETER

COMPLICATIONS

Moderate pneumothorax

Mild pneumothorax

Moderate pneumothorax

Mild pneumothorax

SA = Staphylococcus Aureus MT = Mycobacterium Tuberculosis KL = Klebsiella Pneumoniae

KL SA SA MT MT KL SA MT SA KL KL MT SA SA MT KL MT SA SA SA KL MT KL MT SA SA MT SA KL MT SA SA KL SA SA KL SA MT MT SA

PUS CULTURE

FURTHER MANAGEMENT

Surgery

Chest-tube inserted

Surgery

Chest-tube inserted-Surgery

Surgery

Chest-tube inserted

Surgery

192

M = male W = woman

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

Patient no

Table I. — Data for the 40 patients undergoimg CT-guided transthorasic catheter drainage of intrapulmonary abscess.

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day follow-up of the patient was usually done by the referring physician, including clinical observations, daily tube output measurements, and repeated radiographs and, when necessary, repeated computed tomography with contrast media. Catheter was left in place until the drainage of the pus from the catheter was stopped. Patients were followed till imaging evidenced complete closure of the abscess cavity or decision of surgery was taken due to non closure of the abscess cavity. Success of chest tube drainage was defined as complete closure of the abscess cavity with clinical improvement and avoidance of more invasive procedures (surgery etc). Ideally, there should have been no more than 20 ml of daily drain output.

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Results Thirty patients with lung abscess were men and ten were women. The age range was 26-88 years (mean age 61 years). The decision for the drainage was made due to persistent fever and leucocytosis 1 week after initiation of antibiotic therapy for patients with bacterial pneumonia and due to increase of the size of the abscess while the patient was on medical therapy for patients with diagnosed tuberculosis (9). Immediate technical success was achieved in all the 40 patients. We used the Seldinger technique for tube insertion in seven patients while the direct trocar technique was used in all the other cases. Overall we used thirteen 8F, sixteen 10F and eleven 12F pigtail catheters for the drainage of the lung abscesses. Out of the forty patients, two (5%) developed mild pneumothorax which were managed with aspiration of 200cc of air and administration of supplemental oxygen, while three (8%) developed moderate pneumothorax and chest tube was inserted, and all these three patients had deeply placed abscesses and normal lung tissue had to be traversed to acquire access to the abscess cavity. All the patients showed clinical improvement with resolution of pulmonary symptoms and sepsis (regression of fever, decrease of white blood cell counts). Seven of them (two of them had developed pneumothorax during the procedure), although they demonstrated initial shrinkage of the abscess and clinical improvement, a few weeks later showed recurrence of the

Fig. 1. â&#x20AC;&#x201D; 61-year-old man with right lung abscess and failed medical treatment. A,B. Chest radiograph and CT scan (mediastinal window) show a cavitary lesion with air-fluid level almost filling the right hemithorax representing an abscess. C. CT scan after percutaneous drainage shows immediate decrease in fluid and size of lung abscess.The patient had a rapid symptomatic response to abscess drainage. D. Followup CT scan 6 days after the procedure shows almost complete drainage of the fluid.The abscess cavity completely resolved 3 weeks later and the patient did not need further surgical management.

abscess and needed surgery while the other thirty three patients avoided it . Thus the success rate of the procedure was 83% (33/40) (Fig. 1, 2). Among the thirty three patients who avoided surgery, three needed insertion of extra catheter during the initial procedure due to the presence of multilocular abscess. None of all the forty patients either developed haemoptysis , or was found to have bronchopleural fistula or empyema formation and no mortality occurred during or after the procedure. In thirty out of forty patients, complete resolution of abscess cavity occurred in 4 weeks. In the three patients who needed extra catheter it took 6 weeks and in seven patients abscess cavity persisted 9 weeks till they were operated. The pus culture revealed the presence of Mycobacterium tuberculosis in 12 patients, Staphylococcus

aureus in 18 patients and Klebsiella pneumoniae in 10 patients. Discussion Primary lung abscess usually results from aspiration of anaerobic oropharyngeal bacteria into gravitydependent portions of the lung, most often the posterior segments of the upper lobes and the superior segments of the lower lobes. Consequently, they are seen more commonly in alcoholics and patients with altered levels of consciousness, gastro-esophageal dysmotility and poor dental hygiene (10). Most lung abscesses in paediatric patients are believed to develop secondary to bacterial pneumonia. Other predisposing factors for development of a lung abscess include immunodeficiency or immunosuppression state caused by viral infection,

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Fig. 2. â&#x20AC;&#x201D; 26-year-old woman with lung abscess in the right lower lobe and persistent fever 1 week after institution of antibiotic therapy. A. CT scan shows posterior loculated fluid collection with thick and irregular wall consistent with abscess (the patient is in right lateral decubitus position). B,C. CT-guided percutaneous drainage of the abscess. D. Follow-up CT scan after the procedure shows almost complete drainage of the fluid.

severe systemic illness or steroid therapy. Less common causes are cystic fibrosis, a-1 antitrypsin deficiency, anaesthesia and dental surgery (11). Most abscesses are discovered when fever and pulmonary symptoms lead to a chest radiograph that reveals a solid or cavitary lung mass. CT scans are obtained in all patients with suspected lung abscess to further characterize findings detected on conventional radiographs and to evaluate for obstructing endobronchial lesions. On CT, a lung abscess appears as a rounded intrapulmonary mass that contacts the chest wall at acute angles and contains central necrosis or cavitation. The enhancing wall of an abscess on CT is typically thick with an irregular inner margin (12). Until the early 1940s, surgical pneumonotomy and drainage were the accepted treatments for lung abscess (13). Subsequent advances in anesthesia and surgical techniques led to the advent of lung

resection as the preferred therapy, until availability of effective antibiotics rendered open drainage unnecessary in most patients (14). Current first-line therapy for lung abscess is antibiotic therapy directed at the likely causative organisms, usually anaerobes or mixed aerobic and anaerobic bacteria (15). Surgical or percutaneous drainage is required in 11% to 21% of patients with lung abscess who fail to respond to medical therapy (16). Image guided percutaneous catheter drainage is an alternative to traditional surgical management of lung abscess, and is safe and effective with less morbidity and mortality than surgical resection. Other advantages are rapid clinical and radiological improvement of pyogenic abscess which may avoid complications that can occur with prolonged and conservative treatment (2, 8). Lung abscess may be drained using fluoroscopy or ultrasound guidance, but CT guidance was pre-

ferred in this study. Reasons being, CT is usually performed in all patients with lung abscess before transthoracic placement of the drainage catheter (4). CT is useful in evaluation of the intrathoracic abnormality and helps to differentiate it from necrotizing pneumonia. This is important because catheter drainage of necrotizing pneumonia has proved to have a higher complication rate like hemorrhage, bronchopleural fistula and pneumothorax (17). CT is optimal in determining the wall thickness of an abscess, contents of an abscess and its relationship to the adjacent lung and pleura. More over, any obstructing foreign body or endobronchial neoplasms can also be visualized. Before considering the failure of medical therapy and the need of percutaneous transthoracic drainage it is important to rule out bronchial obstruction and bronchogenic malignancy as these are indications of surgical resection (18). Follow-up CT studies after placement of percutaneous catheter allow optimal assessment of the adequacy of pus drainage and help in determining whether an additional catheter is required (8). Duration of complete closure of cavity is variable and has been reported to occur as early as 4 days (9) or as long as 12 weeks (3), but usually it takes 4 to 5 weeks (2, 6) as occurred in our study. In our study, thirty three of the forty patients with lung abscess were saved from surgery which means that success rate of this procedure is 83%.These results are comparable to the results of the largest series published to date. Van Sonneberg et al. (8) reported successful CT guided percutaneous lung abscess drainage in 19 patients, and surgery was avoided in 16 patients (84% success rate). Surgery was performed in three patients because of adjacent organized pleural tissue that could not be drained via percutaneous catheters. Complications that occurred in Van Sonnenberg study were haemothorax (occurred in one patient, who required chest tube for drainage), clogging of catheter (occurred in two patients, who required catheter exchange) and transient elevation of intracerebral pressure (one patient). Mahira Yunus (1) also reported successful CT-guided transthoracic catheter drainage of intrapulmonary abscess in 19 patients and surgery was avoided in 15 patients (78,94% success rate). Two patients with

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residual cavity and two with bronchopleural fistula were operated, while two patients developed moderate pneumothorax and required chest tube insertion, three patients developed mild pneumothorax and two patients developed mild haemoptysis which both needed no further management. In this study we used the trocar technique for tube insertion in the majority of cases but also Seldinger technique in seven patients, when there was difficulty in the right placement of the catheter. Although some authors in the literature state (8) that the Seldinger technique with placement of catheter over guide wire decreases the likelihood of complications, considering the fact that the complications which occurred during the procedure for all the patients of the series were few and minor (Only five patients with lung abscesses developed mild or moderate pneumothorax), we believe that the choice of technique is depended on the ability, the experience and also the preference of the interventional radiologist performing the procedure. Conclusion CT-guided percutaneous catheter drainage is a useful and safe procedure for the treatment of lung abscesses and should be considered both as a preparatory step for surgery and a valuable alternative to

open surgery. Failure of the procedure does not, however, preclude a subsequent surgical operation. References 1. Yunus M.: CT-guided transthoracic catheter drainage of intrapulmonary abscess. J Pak Med Assoc, 2009, 59: 703-709. 2. Wali S.O., Shugaeri A., Samman Y.S., Abdelaziz M.: Percutaneous drainage of pyogenic lung abscess. Scand J Infect Dis, 2002, 34: 673-679. 3. Shim C., Santos G.H., Zelefsky M.: Percutaneous drainage of lung abscess. Lung, 1990, 168: 201-207. 4. Klein J.S., Schultz S., Heffner J.E.: Interventional radiology for the chest: Image-guided percutaneous drainage of pleural effusion, lung abscess, and pneumothorax. AJR1995, 164: 581588. 5. Kosloske A.M., Ball W.S. Jr., Butler C., Musemeche C.A.: Drainage of pediatric lung abscess by cough, catheter or complete resection. J Pediat Surg, 1986, 21: 596-600. 6. Vainrub B., Musher D.M., Guinn G.A., Young E.J., Septimus E.J., Travis L.L., et al.: Percutaneous drainage of lung abscess. Am Rev Respir, 1978,117: 153-160. 7. Mwandumba H.C., Beeching N.J.: Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema. Curr Opin Pulm Med, 2000, 6: 234-239. 8. Van Sonneberg E., Dâ&#x20AC;&#x2122;Agostino H.B., Casola G., Wittich G.R., Varney R.R., Harker C.: Lung abscess: CT guided drainage. Radiology, 1991,178: 347351.

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9. Rice T.W., Ginsberg R.J., Todd T.R.: Tube drainage of lung abscess. Ann Thorac Surg, 1987,44: 356-359. 10. Erasmus J.J., et al.: Percutaneous management of intrapulmonary air and fluid collections. RCNA, 2000, 38: 4. 11. Asher M.I., Leversha A.M.: Lung abscess. In: Chernick V., Boat T.F., Kendig E.L. Kendig's Disorders of the Respiratory Tract in Children. 6th ed. Philadelphia: WB Saunders Co, 1998, pp 552-60. 12. Stark D.D., Federle M.P., Goodman P.C., Podrasky A.E., Webb W.R.: Differentiating lung abscess and empyema: radiography and computed tomography. AJR, 1983,141 : 163-167. 13. Neuhof H., Touroff A.S.W.: Acute putrid abscess of the lung. V. Hyperacute variety. J Thorac Surg, 1942,12: 98-106. 14. Baker R.R.: The treatment of lung abscess: current concepts. Chest, 1985,87: 709-710. 15. Yang P.C., Luh K.T., Leo Y.C., et al.: Lung abscesses: ultrasound examination and US-guided transthoracic aspiration. Radiology, 1991, 180: 171175. 16. Hogan J.L., Hardy J.D.: Lung abscess revisited. A survey of 184 cases. Ann Surg, 1983, 197: 755-762. 17. Hoffer F.A., Bloom D.A., Colin A.A., Fishman S.J.: Lung abscess versus necrotizing pneumonia: implications for interventional therapy. .Pediatr Radial, 1999, 29: 87-91. 18. Stavas J., vanSonnenberg E., Casola G., Wittich G.R.: Percutaneous drainage of infected and non-infected thoracic fluid collections. J Thorac Imaging, 1987, 2: 80-87.

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LATE PRESENTATION OF URETERAL INJURY FOLLOWING LAPAROSCOPIC COLORECTAL SURGERY A.M. Priola1, S.M. Priola1, G. Volpicelli2 Iatrogenic ureteral injury is an uncommon but dangerous complication of abdominal and pelvic surgery. When recognized and promptly treated, most ureteral lesions heal without sequelae. Instead, undetected injuries may last for a prolonged period of time since symptoms and signs are usually subtle and nonspecific, even if evolution may be life threatening. In doubtful cases the diagnostic role of modern multiphase helical computed tomography is crucial. We describe the late presentation in the Emergency Department of a case of double left ureteral injury after abdominal surgery, and illustrate the appearance of the lesions at computerized tomography. Key-word: Ureter, injuries.

Case report A 53-year-old man presented to our emergency department (ED) complaining of acute flank pain and fever progressively increasing for 3days. His recent medical history included laparoscopic resection of a sigmoid colon carcinoma performed two weeks before. On physical examination the abdomen was mildly distended with slight contracture of the lower abdominal wall muscles, while regular bowel sounds were heard during auscultation. Laboratory blood tests were within the normal range, except for a white blood cell count of 16 x 109/L and a slight increase of C-reactive protein. Abdomen emergency ultrasound was unremarkable, ruling-out peritoneal fluids and free air. Multiphase helical computed tomography (CT) demonstrated a left retroperitoneal urinoma and hyperdense suture material along the transition between the middle and the lower third of the left ureter (Fig. 1A-C). CT images were consistent with incidental ureteral stapler ligation and laceration/section. Multiple intestinal air-fluid levels with bowel distension were detected, suggesting paralytic ileus due to peritoneal irritation (Fig. 1D). Endoscopic ureteral stenting was primarily attempted, but the manoeuvre was unsuccessful thus suggesting a complete obstruction of the ureter. This first endoscopic attempt was then followed by open surgery for complete ureteral reconstruction. Exploration during open surgery confirmed the double injury of the left ureter, due to longitudinal laceration and fully circumferential

ligation few millimetres apart. The lesions were repaired and a ureteral stent was placed and then removed few weeks later, without any complication at follow-up. Discussion Iatrogenic ureteral injury (IUI) is an uncommon but severe complication of any abdominal and pelvic open or laparoscopic surgery, whose incidence ranges from 0.5% to 1% depending on the surgical pathology and surgeon’s experience (1). The predominant risk factor contributing to incidental ureteral injuries is the excessive intra-operative bleeding with difficult haemostasis, owing to blind clamping and suturing (1). IUI is more frequent during gynaecological procedures, mostly radical hysterectomy, that account for 50% of all injuries. Other procedures at risk are urological open and endoscopic surgery (30%) and vascular and general abdominal surgery (515%), mostly aortic and colorectal. Spinal surgery may also cause ureteral injuries, although these are very rare (1). Most cases of IUI are one-side section of the lower half of the ureter, usually identified and repaired during the same surgery session (2). Bilateral ureteral injuries, although rare, can also be iatrogenic (2). When the lesion is intra-operatively recognized and promptly treated, most lesions heal without sequelae and rarely require additional surgery. In case of misdiagnosis, IUI may remain undetected for a prolonged period of time, ranging from several weeks to months after surgery, because symptoms

From: 1. Department of Diagnostic Imaging, 2. Department of Emergency Medicine, San Luigi Gonzaga University Hospital, Orbassano (Torino), Italy. Address for correspondence: Dr G. Volpicelli, M.D., Medicina d’Urgenza, Ospedale Universitario San Luigi Gonzaga, Orbassano (Torino), Italy. E-mail: gio.volpicelli@tin.it

and signs are usually mild and nonspecific. Occasionally, IUI may complicate and even become life threatening (1). The postoperative clinical presentation of IUI may include abdominal and flank or back pain, fever, peritonitis, urinary leakage from the vagina, cutaneous fistula, haematuria and anuria (2). Symptoms are often chronic and slowly progressive. Physical examination may reveal a tender, distended abdomen and sometimes signs of peritoneal irritation. Cases of IUI recognized later are usually associated with serious morbidity, especially sepsis and severe renal failure, and unfavourable outcome (1). Emergency CT scan plays a crucial role in the diagnosis of postoperatively IUI. Multidetectorrow-helical CT scanners allow single breath-hold acquisitions of the abdomen and pelvis with narrow collimation using a slice thickness and increment of 1 to 1.25 mm (3). Thin-section axial CT images obtained during the excretory phase of enhancement are then evaluated with two-dimensional multiplanar reformation (MPR) and threedimensional (3-D) reconstruction images generated on workstations from axial source images. MPR and 3-D reformation images provide orthogonal, coronal or oblique planes, which help to define the location and extent of the lesions previously shown by axial CT images (3). The delayed phase (excretory or urographic phase) useful to evaluate renal collecting system and ureters, begins at least 10 minutes after the first injection of contrast medium and is crucial for visualizing the exact location of the injury, at the level of the collecting system, the pelvic junction or the ureter. The injury is usually evidenced by the extravasation of excreted contrast (4). CT images are also useful to specify the type of

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B Fig. 1. â&#x20AC;&#x201D; A. Pre-contrast axial 64-rowCT-scan showing a retroperitoneal welldefined fluid-collection of water-density anterior to the left psoas major muscle (arrow). Hyperdense suture material is detected along the transition between the middle and the lower-third of the left ureter (straight arrow), close to the free fluid retroperitoneal collection, suggesting ureteric ligation. Inflammatory changes in the peri-ureteral tract with thickening of the fascial planes are observed (R = right ureter). B. Contrastenhanced CT scan obtained during the nephro-graphic phase demonstrating initial urinary contrast leakage into the fluid collection (arrow). C. Delayed scan obtained 15 minutes after contrast injection (pyelo-graphic phase) demonstrating extravasation of contrast medium excreted from the kidney within the left retroperitoneal fluid collection (arrows), consistent with ureteric laceration resulting in retroperitoneal urinoma. The ureter distal to the site of injury is not opacified for ligation (coronal MIP reformation, straight arrow), not allowing CT-distinction between laceration and trans-section. A mild ipsilateral hydroureteronephrosis is observed (R = right ureter; B = bladder). D. CT scan obtained during the nephro-graphic phase demonstrates normal enhancement of the left kidney. Note the multiple intestinal air-fluid levels with bowel distension (arrowheads), suggesting paralitic ileus supported by peritoneal irritation.

injury (laceration/perforation, section, ligation, stricture), together with extension of the lesion and possible associated complications (retroperitoneal urinomas or urinary ascites) (2). The CT hallmark of ureter injuries is extravasation of urine, which may collect at different sites.

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Extra luminal urine may appear as a water-density fluid collection of any size, usually not distinguishable from ascites. On CT images, the fluid collection can be proved to be an urinoma only when it becomes opaque due to leakage of contrast medium excreted by the kidney.

Delayed phase CT scans, usually obtained 10-15 minutes after contrast material injection, are considered optimal for demonstrating ureteral urine leak, with a reported sensitivity of 100% (5). Lack of impregnation of a distal ureter after contrast medium injection, is another CT sign of ureteral rupture. However, if the ureter is only lacerated and not completely interrupted, the ureter distal to the injury may still show some contrast enhancement (5). In the

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case of contrast enhancement of the abdominal fluid collection, the differential diagnoses include also other diseases owing to leakage of oral contrast material from the gastrointestinal tract or from ruptured blood vessels (6). The absence of free peritoneal air together with delayed contrast enhancement of a confined fluid collection and some degree of dilation of the upper renal collecting system, are highly indicative of some injury of the urinary tract (2, 6). In some cases, it is not possible to identify the exact site of leakage of contrast material. Misdiagnosis is usually due to the flowing of the urine collection away from the ureteral lesion, often accumulating in the retroperitoneal compartment or even the upper abdomen. These conditions can be achieved when the fascial planes for some reason are discontinuous (7). The differential diagnosis of a postoperative fluid collection includes also other conditions than urinoma, such as lymphocele, hematoma, seroma and abscesses. CT study with acquisition of delayed scans targeted to the visualization of contrast enhancement of the fluid collection, is crucial for ruling out other possible diagnoses and

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demonstrate the urine collection (5). Furthermore, CT is useful to plan the correct management (endoscopic or open reconstructive procedures) and to identify complications on followup, such as ureteral stricture (2). When non-absorbable suture is used during surgery, postoperatively late detection of ureteric ligation may manifest as chronic hydroureteronephrosis with complete loss of renal function, which ultimately requires nephrectomy (8). Accidental ligation performed by absorbable suture has a better prognosis, and may be best treated by proximal drainage alone with the positioning of a percutaneous nephrostomy tube (9). This conservative strategy may be applied only if the continuity of the ureter is preserved. In our patient the immediate open surgical intervention was mandatory (9). Whether laceration was produced during surgery, with dripping of urine in the retro-peritoneum during the following two weeks, or few days before presentation in the ED, by mechanic pressure due to urine stasis due to ligation, remains unclear. Anyway, laceration presumably allowed a relatively early diagnosis even if postoperative, and preservation of the kidney.

References 1.

Selzman A.A., Spirnak J.P.: Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries. J Urol, 1996, 155: 878-881. Gayer G., Hertz M., Zissin R.: Ureteral injuries: CT diagnosis. Semin Ultrasound CT MRI, 2004, 25: 277-285. Kocakoc E., Bhatt S., Dogra V.S.: Renal multidetector row CT. Radiol Clin N Am, 2005, 43: 1021-1047. Stuhlfaut J.W., Anderson S.W., Soto J.A.: Blunt abdominal trauma: current imaging techniques and CT findings in patients with solid organ, bowel, and mesenteric injury. Semin Ultrasound CT MRI, 2007, 28: 115-129. Gayer G., Zissin R., Apter S., et al.: Urinomas caused by ureteral injuries. Abdom Imaging, 2002, 27: 88-92. Gayer G., Hertz M., Manor H., et al.: Dense ascites: CT manifestations and clinical implications. Emerg Radiol, 2004, 10: 262-267. Kenney P.J., Panicek D.M., Witanowski L.S.: Computed tomography of ureteral disruption. J Comput Assist Tomogr, 1987, 11: 480-484. Pua U., Quek L.H.: Inadvertent ureteric ligation: diagnosis using multidetector computed tomography. Urology, 2009, 74: 1015-1016. Lask D., Abarnel I., Luttwak Z., et al.: Changing trends in the management of iatrogenic ureteral injuries. J Urol, 1995, 154: 1693-1695.

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TESTICULAR SARCOIDOSIS M. Eyselbergs1,2, R. D’Hauwe3, K. De Cuyper1, M. Camerlinck1,2, B. Van Aken4, R. Oyen3, F.M. Vanhoenacker1,2 We describe a very unusual form of sarcoidosis of the testis, mimicking malignancy at initial presentation. Genitourinary sarcoidosis is rare and this case report emphasizes the importance of meticulous analysis of the patient’s clinical history combined with imaging findings and specific pathological criteria to diagnose this granulomatous disorder. Key-word: Sarcoidosis.

Case report A 40-year-old Caucasian male patient was referred by his general physician to the hospital for the assessment of a palpable painless mass of the right testis and a dry cough with mild dyspnea for 6 weeks. The pulmonary complaints improved with non-steroidal antiinflammatory drugs. The patient had no fever and no B-symptoms. There was absence of weight loss. The previous medical history and routine blood examination were unremarkable. Clinical examination confirmed the right testicular mass but also an enlarged mass at the right inguinal region. Scrotal ultrasound showed bilateral, well delineated hypoechoic lesions within the testicular parenchyma (Fig. 1). Color-Doppler showed only subtle intralesional vascularisation. Multiple enlarged inguinal lymph nodes were seen bilaterally. A chest X-Ray showed bilateral hilar lymphadenopathies and multifocal lung nodules (Fig. 2). Computed tomography (CT) showed multiple irregular delineated pulmonary micro- and macronodules with peribronchovascular distribution pattern, irregular septal thickening and multiple mediastinal lymph nodes. On the abdominal series, a hypoattenuating splenic lesion (3 cm) and multiple enlarged mesenteric, retroperitoneal and inguinal lymph nodes were seen (Fig. 3). Laboratory results including serum angiotensin converting enzyme (389 U/L - normal value 115-419 U/L) and specific tumor markers (lactate dehydrogenase (340 U/L - normal value 237-475 U/L), serum alphafetoprotein (1,8 µg/L - normal value

B Fig. 1. — Ultrasound of the right testis (A), right inguinal lymph node (B). Image A demonstrates a normal volume of the testis and multiple sharply demarcated hypoechoic intratesticular nodules. Image B demonstrates the pathological enlarged right inguinal lymph node from which a biopsy specimen was obtained.

From: 1. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen, 2. Department of Radiology, UZ Antwerpen, Edegem, 3. Department of Radiology, University Hospitals Gasthuisberg, Leuven, 4. Department of Pneumology, AZ Sint-Maarten, DuffelMechelen. Address for correspondence: Pr Dr F.M. Vanhoenacker, M.D., Ph.D., Department of Radiology, AZ Sint Maarten, Rooienberg 25, B-2570 Duffel, Belgium and University of Ghent, Belgium. E-mail: fillip.vanhoenacker@telenet.be

< 6,1 µg/L) and human chorionic gonadotropin (< 1,0 U/L - normal value < 2,5 U/L)) were within normal ranges. Based on the clinical history and imaging studies, the differential diagnosis included testicular malignancy with metastatic spread to

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abdominal lymph nodes and the lungs. This however was contradictory with the lab results. The differential diagnosis further included lymphoma and systemic disease such as a granulomatous disease. Based on the routine blood examination, chronic infectious process such as tuberculosis was unlikely. Finally, histological examination of a biopsy specimen from an inguinal lymph node revealed the diagnosis of sarcoidosis. Retro-anamnesis revealed itchy lesions at the lower limbs several weeks ago consistent with erythema nodosum. Apparently, treatment with topical corticosteroid therapy relieved the complaints and the precise etiology of the skin lesions remained unclear after this clinical contact. Further pulmonary work up was consistent with the diagnosis of sarcoidosis: spirometry showed a slightly decreased total lung capacity suggesting a restrictive lung pattern with normal diffusion capacity. No

Fig. 2. â&#x20AC;&#x201D; Postero-anterior radiograph of the thorax displays bilateral hilar adenopathies (arrows) with multiple nodular opacities bilaterally (arrowheads) with dominant predilection for the upper lobes.

Fig. 3. â&#x20AC;&#x201D; Axial (A, B and C) contrast-enhanced CT of the abdomen and pelvis (D). Figure A demonstrates clearly a well demarcated hypodense intrasplenic lesion 3 cm in size. Image B demonstrates multiple enlarged lymph nodes at the retroperitoneum and gastrohepatic ligament (circle) and image C an enlarged paraaortic lymph node (arrow). Figure D demonstrates the pathological lymph node aggregate (circle) in the right inguinal region from which the biopsy was obtained.

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other vital organs were involved and the patient is in follow up every 4 months. Discussion Sarcoidosis is a systemic granulomatous disease of unknown multifactorial etiology in which the combination of an unbalanced immune system, genetic predilection and environmental impact are key factors (1). The disease primarily affects young African-American female adults. The estimated prevalence is 1 to 6 cases per 100000 people worldwide with a peak incidence that occurs between the third and fifth decade. The histological hallmark is the occurrence of non-caseating epitheloid granulomas and multinucleated giant cells (2). The final diagnosis is based on the combination of clinical, radiological and histological features and after exclusion of other pathologies with similar histology characteristics (3). In cases where a biopsy cannot be obtained, diagnosis is based on the clinical and radiographic features in addition to certain demographic information (4). In sarcoidosis, pulmonary and lymph node involvement are the two most frequently affected organ sites. Extrathoracic involvement occurs in 15-45% of patients, involving many organs including the spleen, liver, skin, eyes, muscles, central nervous system and salivary glands (5). Male genitourinary involvement is an unusual manifestation of this granulomatous disease reported in approximately 0,2% of all sarcoidosis patients (6). The incidence of genital sarcoidosis at necropsy series is less than 5% (7). Imaging features of pulmonary sarcoidosis on conventional radiographs and CT include bilateral hilar adenopathies and involvement of lung parenchyma (8). Further discussion of the pulmonary imaging features is beyond the scope of this case report. Abdominal sarcoidosis may mimic other systemic diseases such as lymphoma, tuberculosis or metastases with hepatosplenomegaly being the most frequent imaging finding. Nonspecific focal hepatosplenic lesions (8-10), as demonstrated in our patient, are less frequent (Fig. 3).

For evaluating the scrotal content, ultrasonography is the key imaging modality. Multiple hypoechoic and hypovascular lesions that synchronously affect the epididymis and testis are typical for testicular sarcoidosis. These lesions are rather small (ranging from a few millimeters to 3 cm), nodular and sharply demarcated. When bilateral hypoechoic testicular solid nodules are found, the differential diagnosis is wide. Although testicular tumors represent only 1% of all malignant neoplasms in men, it is the most common malignancy in men aged 15-34 years (11) and this is the same age group in which sarcoidosis of the testis is most frequent (12). However, in our patient the presence of a primary testicular tumor is unlikely since the prevalence of bilateral testicular neoplasms is very low (1-3%). Bilateral multifocal testicular tumors mimicking testicular sarcoidosis include seminoma, Leydig cell nodules (Leydigiomas), adrenal rests, chronic granulomatous disease processes, lymphoma, leukemia and metastasis (11). Seminoma may be bilateral in approximately 3% of the cases. Multiple and bilateral Leydig cell nodules are incidental findings in patients referred for subfertility. Adrenal rests are part of a syndrome and present as tail-shaped lesions located near the rete testis. Lymphoma and leukemia usually have a sonographic appearance of bulky masses involving major parts of the testicular parenchyma, which is clearly not the case in our patient. Also, metastasis to the testis has been reported and needs to be considered (melanoma, gastric cancer and prostate carcinoma). In addition, the absence of specific tumor markers as lactate dehydrogenase, serum alphafetoprotein and human chorionic gonadotropin are helpful in differentiating sarcoidosis from primary testicular tumor. The distribution of lymph nodes is also helpful for further narrowing the differential diagnosis. Inguinal lymph node metastases would indicate scrotal involvement of a primary testicular tumor, which was completely ruled out based on the imaging studies. The sentinel nodes for testicular tumors are the retroperitoneal areas near the renal hilum (11).

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Conclusion Genitourinary sarcoidosis is extremely rare and ultrasound is the primary imaging modality to evaluate the scrotal content. The combination of a detailed patient history, laboratory results and documentation of multisystem involvement on chest X-rays and CT of the chest and abdomen allow narrowing of the differential list. Histological confirmation is essential for a final diagnosis. References 1. Nunes H., Bouvry D., Soler P., Valeyre D.: Sarcoidosis. Orphanet J Rare Dis, 2007, 2: 46. 2. Hoang D.Q., Nguyen E.T.: Sarcoidosis. Semin Roentgenol, 45: 36-42. 3. Stewart V.R., Sidhu P.S.: The testis: the unusual, the rare and the bizarre. Clin Radiol, 2007, 62: 289-302. 4. Parrish S., Turner J.F.: Diagnosis of sarcoidosis. Dis Mon, 2009, 55: 693703. 5. Waanders F., van Hengel P., Krikke A., Wesseling J., Nieboer P.: Sarcoidosis mimicking metastatic disease: a case report and review of the literature. Neth J Med, 2006, 64: 342-345. 6. Kodama K., Hasegawa T., Egawa M., Tomosugi N., Mukai A., Namiki M.: Bilateral epididymal sarcoidosis presenting without radiographic evidence of intrathoracic lesion: Review of sarcoidosis involving the male reproductive tract. Int J Urol, 2004, 11: 345-348. 7. Ricker W., Clark M.: Sarcoidosis; a clinicopathologic review of 300 cases, including 22 autopsies. Am J Clin Pathol, 1949, 19: 725-749. 8. Prabhakar H.B., Rabinowitz C.B., Gibbons F.K., Oâ&#x20AC;&#x2122;Donnell W.J., Shepard J.A., Aquino S.L.: Imaging features of sarcoidosis on MDCT, FDG PET, and PET/CT. AJR Am J Roentgenol, 2008, 190: S1-6. 9. Park H.J., Jung J.I., Chung M.H., et al.: Typical and atypical manifestations of intrathoracic sarcoidosis. Korean J Radiol, 2009, 10: 623-631. 10. Warshauer D.M., Lee J.K.: Imaging manifestations of abdominal sarcoidosis. AJR Am J Roentgenol, 2004, 182: 15-28. 11. Woodward P.J., Sohaey R., Oâ&#x20AC;&#x2122;Donoghue M.J., Green D.E.: From the archives of the AFIP: tumors and tumorlike lesions of the testis: radiologic-pathologic correlation. Radiographics, 2002, 22: 189-216. 12. Rao P.K., Sabanegh E.S.: Genitourinary sarcoidosis. Rev Urol, 2009, 11: 108-113.

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IMAGING IN INDEX FINGER RADIAL COLLATERAL LIGAMENT INJURY: ATTENTION TO DETAIL REALLY PAYS… N.C. Chotai, S.C. Tham, G. Wansaicheong, A.A. Tandon1 Radial collateral ligament of the index finger is a rare ligament to rupture. X-ray is generally normal, except for subtle findings of soft tissue swelling and occasionally a small fracture. With continuous advances in imaging, ultrasound and high quality MRI allow clear depiction of small structures including joint capsule and collateral ligaments of even the small joints. This helps in definitive diagnosis and determines the extent of injury, which may affect the treatment options and final outcome. We report a rare case of index finger metacarpo-phalangeal joint radial collateral ligament tear. The subtle X-ray abnormality was chased on ultrasound and the diagnosis was proposed on ultrasound and later confirmed on MRI. We also discuss the imaging findings of this rare entity. Key-word: Fingers and toes, injuries.

The stable pinch mechanism depends on the integrity of the radial collateral ligament (RCL) of the index finger (IF) and ulnar collateral ligament of the thumb metacarpo-phalangeal joints (MCPJ). Injury to the collateral ligament of the MCPJ is common in the thumb and small finger, these being the border digits. Index finger MCPJ collateral ligament is rare to get injured. Plain radiograph may have subtle findings which are easily missed. Improved resolution on ultrasound and MRI are creating great interest amongst the radiologists and clinicians to utilize these facilities for making early, definitive diagnosis of these injuries and to predict their extent. Also it helps to diagnose other associated injuries, which might affect the treatment and overall prognosis.

Fig. 1. — X-ray of the left hand in frontal and oblique views shows a small bone fragment (arrow) at the radial aspect of the base of the proximal phalanx of the index finger. Note minimal overlying soft tissue swelling.

Case report A 54-year-old energetic police man was referred to our institution with a history of persistent painful swelling over the MCPJ of the left index finger for 2 months. Clinical history revealed remote trauma. The patient was treated conservatively without much symptomatic relief. Radiograph of the left hand showed a small bone fragment at the radial side of the base of the proximal phalanx of the index finger (IF) with minimal overlying soft tissue swelling (Fig. 1). Due to persistent symptoms, further evaluation was carried out with ultrasound, which confirmed the X-ray finding. Additionally it demonstrated thickening with increased echogenicity of the radial collateral ligament (RCL) (Fig. 2). Dynamic stress testing also

confirmed this deficiency. Radial collateral ligament tear was proposed diagnosis. This was further confirmed on MRI, which showed partially torn fibers of RCL at MCPJ on PD and inversion recovery images (Fig. 3) with associated disruption of the radial sagittal band (Fig. 4). T2-weighted images showed increased signal in the ligament, surrounding soft tissue and marrow of the adjacent proximal phalanx. Gradually the patient improved symptomatically without any surgical intervention. Discussion Integrity of the RCL of the index finger MCPJ and the ulnar collateral ligament (UCL) of the thumb MCPJ

From: 1. Department of Diagnostic Imaging, Tan Tock Seng Hospital, Singapore. Address for correspondence: Dr N.C. Chotai, Department of Diagnostic Imaging, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433. E-mail: niketachotai@yahoo.com

predicts a stable pinch mechanism. The RCL is thicker, wider, stronger, more oblique and closer in its origin to the articular surface of the metacarpal head than the UCL (1). Inadequately treated trauma to these ligaments can lead to pain, instability, and weakness of pinch. In 2006, Gaston and Lourie (2) proposed 3 grades of injury: tenderness over the RCL without instability (Grade 1), laxity with a definite end point (Grade 2) and laxity without endpoint (Grade 3). Though rare, this entity is of major clinical significance (2). Support by the first dorsal interosseous muscle and laxity of ligaments in neutral position contribute to its rarity. One study has reported that a force of about 43 kg was necessary to rupture the RCL of the IF (3). RCL tears can be at the metacarpal head, proximal phalanx or mid-substance in descending order of frequency (4). Common presenting symptoms are history of trauma, local pain,

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INDEX FINGER RADIAL COLLATERAL LIGAMENT INJURY — CHOTAI et al

Fig. 2. — Ultrasound image of radial aspect of proximal interphalangeal joint of the index finger. The small bony fragment (avulsion fracture) is seen on ultrasound (thin white arrow). The radial collateral ligament is thick with increased echogenicity (arrowheads).

dysfunction and joint instability while using the grip. Examination commonly reveals swelling, local tenderness and laxity to ulnar stress with the IF MCPJ in 60 degree flexion (4). The history and physical examination are usually sufficient to make the diagnosis (5). Radiographs are generally unremarkable or occasionally show an avulsion fracture, as in our case. Ultrasound reveals injury to the ligament as thickening and increased echogenicity of the ligament. Associated joint effusion and occasionally avulsed bone fragment may be seen, as was noted in our case. Today, high quality MRI performed with a dedicated wrist coil has replaced the arthrography, which was previously considered the most effective way to image these injuries. It allows localization of the site of injury, extent of tear and identifies associated injuries including extensor hood tear, volar plate and capsular trauma, chondral shearing and occult fractures. MRI may reveal sprain, partial or complete tear of the RCL. Sprain of the ligament is seen as increased signal intensity in the ligament with abnormal morphology. Complete tear is seen as a gap on the sequential images. Partial tear is seen as increased signal intensity and partial discontinuity without retraction. In acute injury, associated joint effusion, bone marrow edema pattern can be seen on T2-weighted images. Chronic tears are seen as thickening and abnormal contour of the ligament (4). Coronal images best show injuries to the collateral ligaments, axial images show injuries to the dorsal capsule, while sagittal images show joint alignment, volar plate and cartilage lesions. Treatment of this injury is usually conservative, and surgical intervention is considered only in cases of significant instability or similar to

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B the Stener lesion of UCL of the thumb. The latter is an interposition of the extensor hood, the sagittal band, or the interosseous tendon between the torn ligament and its attachment (4). In conclusion, injury to the RCL of the IF is a rare but clinically significant injury due to its effect on functionality of the active limb. A high grade of clinical suspicion with attention to subtle findings on the radiograph helps to suggest the diagnosis. Imaging, especially MRI, plays a crucial role in confirming the diagnosis and determining the extent of rupture along with diagnosing associated injuries. References 1.

Minami A., An K.N., Cooney III W.P., Linscheid R.L., Chao E.Y.S.: Ligamentous structures of the metacarpophalangeal joint: A quantitative anatomic study. J Orthop Res, 1984, 1: 361-368. 2. Gaston R.G., Lourie G.M., Peljovich A.E.: Radial collateral ligament injury of the index metacarpophalangeal joint: An underreported but important injury. J Hand Surg, 2006, 31A: 1355-1361.

Fig. 3. — Coronal PD (A) and IR MRI images (B) show partially torn radial collateral ligament at metacarpophalangeal joint (arrow) of the index finger. Marrow edema is seen at the base of the proximal phalanx (arrowheads). C is the schematic diagram of the radial and ulnar collateral ligaments at the index finger for comparison.

Fig. 4. — Axial inversion recovery image at the same level reveals disruption of radial sagittal band (arrow) with high signal in the surrounding soft tissue and bone marrow suggesting edema.

3. Moberg E., Stener B.: Injuries to the ligaments of the thumb and fingers: Diagnosis, Treatment and Prognosis. Acta Chirurgica Scandinavica, 1953, 106: 166-186. 4. Kang L., Rosen A., Potter H.G., Weiland A.J.: Rupture of the radial collateral ligament of the index metacarpophalangeal joint: Diagnosis and surgical treatment. J Hand Surg, 2007, 32A: 789-794. 5. Doyle J.R., Atkinson R.E.: Rupture of the radial collateral ligament of the metacarpophalangeal joint of the index finger: A report of three cases. J Hand Surg, 1989, 14B: 248-250.

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ABNORMAL LEFT SINGLE PULMONARY VEIN: CASE REPORT OF AN ANECDOTAL VARIANT M. Bersou1, P. Mailleux1 We describe here a patient with a very rare ectopic unilateral single pulmonary vein, with normal distal drainage into the left atrium, and thus a non pathologic finding to be distinguished from clinically significant abnormalities. Key-word: Pulmonary veins, abnormalities.

MDCT of the chest with intravenous injection of contrast is the current gold standard to exclude pulmonary embolism or metastasis. The radiologist should know all the variations of the pulmonary vascularization and recognize those potentially clinically significant and those not. Pulmonary veins may vary in course, in origin or destination, in number or in size. We describe here a patient with a very rare ectopic unilateral single pulmonary vein, with normal distal drainage into the left atrium, and thus a non pathologic finding.



Contrast chest CT was performed in an 84-year-old lady for persistent infiltrates on plain chest X-ray. A large vein in the left lung showed a very abnormal course through the left lung, (Fig. 1 A-D): it starts as a left superior vein, climbs up, crosses the fissure and goes down through the left lower lobe, joining the inferior pulmonary vein to drain normally into the left atrium (Fig. 2).



Case report

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Discussion Pulmonary veins variations can be clinically significant, when there is an abnormal partial venous return with left-to-right shunt. It can be an anecdotal finding, as in this case, where the only abnormality is the trajectory and the number, without shunt. A review of the literature revealed around 20 cases of anomalous unilateral single pulmonary vein (AUSPV) (1). Four cases similar to our case were reported. The rightsighted cases are more frequent, and a case of bilateral single pulmonary vein was described (2). The first case of left AUSPV has been reported in 1968 (1, 2). This congenital anomaly could be the result of atresia or hypoplasia of one of the major pulmonary

Fig. 1. — MDCT with contrast: from top to below. A shows the top of the abnormal vein (white arrow). B shows the vein (white arrow) crossing the main left fissure (arrow heads). C: ascending course of the vein (black curved arrow) trough the left upper lobe and medial descending course (white arrow) of the vein along the thoracic aorta (black star). D: Origin of the vein in the lingular area, passing near from the hilum of the left lung (curved black arrow) and his end (white arrow) draining into the left atrium (white star) after joining the left inferior pulmonary vein. CT parameters in this case were the following: 64 slices MDCT, 1,25 mm thin slices, 100 kV, 255 mAs resulting in patient in a CTD/vol of 4,16 mGy, and DLP 143,37 mGy-cm.

veins (3). The congenital abnormalities of the pulmonary venous system may vary according to their origin, their drainage, course, or number. Some authors distinguish the AUSPV from a variant called “the meandering pulmonary vein”, which has a curved course through the

From: 1. Department of Radiology Clinique Saint-Luc, Bouge, Belgium. Address for correspondence: Dr M. Bersou, M.D., Clinique Ste Elisabeth, avenue De Fré 206, 1180 Brussels, Belgium. E-mail: maxime.bersou@skynet.be

lung and drains into the inferior vena cava and/or in the left atrium directly, not via the inferior pulmonary vein like in this case (4). MDCT after intravenous injection of contrast allows to differentiate congenital anomalies of the pulmonary veins which can be classified in three different categories (5) : (a) anomalous pulmonary venous drainage, partial or total, with or without abnormal course in the lung, (b) anomalous

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 Fig. 2. — Thickened-MIP oblique slice showing the end of the AUSPV (white arrow) joining the left inferior pulmonary vein (curved black arrow) to drain into the left atrium (black star).

pulmonary venous route with normal drainage (like this case), and (c) abnormal venous diameters (varices, stenosis and atresia). The pattern of anomalous pulmonary venous drainage presents a pulmonary venous blood flowing directly into the right heart or the systemic veins, partially or totally, causing a right-to-left shunt. The total anomalous drainage is uncommon and is associated with an obligatory septal defect causing a right to left shunt. A thirty of different anomalous connections were made, classified by supracardiac, cardiac, infradiaphragmatic or mixed. Those anomalies may be seen on chest Xray, but are more characterized by contrast-enhanced CT. A pulmonary venous hypertension may be caused when the entire venous drainage of an entire lung passes into the right atrium without septal defect. The main example of anomalous pulmonary venous drainage is the hypogenetic lung (Scimitar) syndrome. It is characterized by hypoplasia of the right lung and anomalous pulmonary venous drainage from it to the inferior vena cava (IVC), and rarely the suprahepatic portion of the IVC, hepatic veins, portal vein, azygos vein, coronary sinus or right atrium. It may be associated with cardiovascular anomalies, anomalies of the right bronchial tree, diverticula, and, occasionally, with extension of a portion of the right lung across the midline

Fig. 3. — Lateral view of a 3D volume rendering-reconstruction of the abnormal vein, starting in the lingular area, passing near from the hilum, ascending to the apex, crossing the fissure, and descending to finally drain into the left atrium, after joining the left inferior pulmonary vein.

into the left hemithorax. The abnormal course of the vein is usually visible on chest X-ray with a curved shadow descending to the diaphragm, right to the heart, mimicking a Turkish sword (or scimitar). In literature (6), different cases of AUSPV were confused with an arteriovenous malformation on plan chest X-ray. The difference must be made with further investigation before any intervention, even in the absence of symptoms due to a right-to-left shunt (reduction in the arterial oxygen saturation, cyanosis, polycythemia or paradoxical emboli). Incidence of AVM rises in context of Osler-Rendu disease, Fanconi's syndrome and polysplenia syndrome. The tortuous aspect of the AUSPV may be confused with a varix, particularly on angiography, which is a dilated and tortuous aspect of a pulmonary vein normally entering to the left atrium without course abnormality (3). The AUSPV is very rare, asymptomatic and has no consequence, not being associated with a left-to-right shunt. No further diagnostic test or treatment is needed. The only relevant clinical implication of such a variant would be in case of a lobectomy, because the vein crosses the fissure (7). Conclusion Classification of congenital anomalies of the pulmonary venous sys-

tem is complex. The radiologist must be aware of the many variations and distinguish relevant variations (such as those causing left-to-right shunts) from incidental findings. References 1.

5. 6.

Gilkeson R.C., Haaga J.R., Ciancibello L.M., Anomalous Unilateral Single Pulmonary Vein. Multidetector CT Findings. AJR, 2000, 175: 1464-1465. Agarwal P.P., Seely Jean M., Matzinger Fred R., MDCT of anomalous unilateral single pulmonary vein. AJR, 2004, 183: 1241-1243. Hasuo K., Numaguchi Y., Kishikawa T., Ikeda J., Matsuura K.: Anomalous unilateral single pulmonary vein mimicking pulmonary varices. Chest, 1981, 79: 602-604. Tortoriello T.A., Vick III G.W., Chung T., Bezold L.I., Vincent J.A.: Meandering Right Pulmonary Vein to the Left Atrium and Inferior Vena Cava. The First Case with Associated Anomalies. Tex Heart Inst J, 2002, 29: 319-323. Remy-Jardin M., Remy J.: Spiral CT Angiography of the Pulmonary Circulation. Radiology, 1999, 212: 615-636. Tsang T.K., Kwan T.L., Wong W.K., Fung H.S., Wai A.M.W.: Anomalous Unilateral Single Pulmonary Vein - a Rare Mimicker of Pulmonary Arteriovenous Malformation. J HK Coll Radiol, 2007, 10: 16-18. Sato M., Tanaka D., Nakajo M.: Meandering pulmonary veins with a common inferior trunk: an anomalous left inferior pulmonary vein entering an anomalous right inferior pulmonary vein. Radiat Med, 2007, 25: 426-429.

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UNUSUAL CLINICAL MANIFESTATION OF LYMPHANGIOMATOSIS O. Prieur1, N. Damry1, C. Heijmans2, C. Christophe1 A 6-year- old boy presented with disseminated intravascular coagulation and was diagnosed with lymphangiomatosis. Disseminated intravascular coagulation develops in a minority of cases. Bone lesions were present on his left shoulder. The authors discuss the diagnostic findings and medical management. Key-word: Lymphangiomatosis.

Lymphangiomatosis is a condition of lymphatic tissue malformation with diffuse involvement of soft tissues, lungs, abdominal organs, and bones. The clinical presentation is varied and can be confusing, with diagnosis made at autopsy. We report a case of this rare disease, emphasizing on its clinical presentation, diagnosis, radiographic findings and potential treatment options. Case report A 6-year-old boy was brought to the emergency department of our hospital for abdominal pain and bloody vomits. His past history reveals bruises on the lower limbs and multiple petechiae on the thorax, face and neck for 2 weeks. Clinical examination excluded hepatosplenomegaly and acute chirurgical disease. Biological tests showed pancytopenia, prolonged coagulation times (activated partial thromoplastine APTT) and a low fibrinogen level. He was transferred to the intensive care unit. Hematological tests normalized over a few days after management of disseminated intravascular coagulation (DIC) and pancytopenia with blood and fresh frozen plasma transfusion. Bone aspiration showed a rich bone marrow without blastic infiltration. Bacteriological tests and a search for a primitive coagulopathy were negative. The child was discharged and followed-up monthly in the outpatient oncology clinic. During one of his visits, clinical examination found a painful cough, which motivated the realization of chest X-ray. The biology results revealed a high level of D-Dimers and a prolonged APTT.

Fig. 1. — X-ray of the left humerus showing multiple lytic lesions in the left humerus extending to the shoulder blade.

Chest X-ray showed no pulmonary or pleural lesion, but unveiled major lytic lesions in the left humerus extending to the shoulder blade (Fig. 1). These geographic bone lesions had sharply defined border with thick or thin sclerotic rim (Lodwick IA and IB). Abdominal ultrasound didn’t showed lesions in the spleen or the liver. A complementary whole-body investigation

From: 1. Department of Radiology, 2. Department of Oncology, Reine Fabiola Children Hospital, Brussels, Belgium. Address for correspondence: Dr O. Prieur, M.D., Department of Radiology, Reine Fabiola Children Hospital, 1020 Brussels, Belgium. E-mail: prieurolivier@yahoo.fr

with magnetic resonance imaging (MRI) was indicated. MRI of the left humerus and shoulder blade showed multiple lacunar lesions involving the cortical and medullary bones of the glenoid fossa, the metaphysis and diaphysis of the proximal humerus. The lesions were hyperintense on T2, hypointense on T1-weighted images and enhanced after intravenous gadolinium injection (Fig. 2). No similar lesions were seen in the all body. Bone biopsy excluded malignancy as well as Langerhans cell histiocytosis.

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D C Fig. 2. — Sagittal STIR (A), sagittal T2 (B), coronal T1 (C), and Gadolinium enhanced axial T1 with fat saturation MR-images showing multiple lacunar lesions involving the cortical and medullary bones of the left humerus, enhancing after injection.

Management consisted of surveillance of lesions and blood analysis. Discussion Lymphangiomatosis is a rare, benign disease resulting from abnormal development of the lymphatic system. Unlike lymphangiomas, in which there is a focal proliferation of lymphatic tissue (30 % at the head and neck level), lymphangiomatosis is a disease of diffuse infiltration via lymphatic channels involving one or more soft tissue organs and the skeleton. The disease can occur at any age, but commonly is found in patients 20 years of age

or younger, and has no sex predilection. In 65% of the patients there is affection of soft organs (mostly in the spleen, the liver, and the lungs) and the skeleton (the long bones, the pelvis, the skull and the vertebrae). The diagnosis of lymphangiomatosis is made through clinical suspicion combined with radiographic and pathologic findings (1). Bony lesions may present as solitary or multiple. On radiography, bone lesions have a well-defined rim of sclerosis that varies in size. Medullary involvement usually predominates. Bony infiltrates are commonly seen at the diaphysis or metaphysis of the tibia and humerus

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as well as the ilium, skull, mandible and vertebrae. The lesions, in our case, present with these features. Differential diagnoses include histiocytosis, hemangiomatosis, infection in children. If the lesion is solitary, it is necessary to exclude fibrous dysplasia, aneurysmal bone cyst, Langerhans cell histiocytosis, giant cell tumor, chondromyxoid fibroma or non ossifying fibroma. Bone biopsy is often negative and enables especially to exclude a neoplastic process. Biopsy of the ribs yields better results. Macroscopically, the lesion looks like multiple communicating cysts which are either empty or contain some blood or a clear fluid or proteins. These cysts are separated by partitions. Histologically, these lesions do not differ from cavernous or capillary angiomas and even lymphangiomas. In the case of a focal bone lesion the evolution is generally favorable with stabilization or spontaneous regression. Gorham-Stout syndrome is characterized by a massive osteolysis associated with extended proliferation of bone lymphatic vessels. The disease is often diagnosed after a pathological fracture and widespread bone resorption can lead to delayed extensive fibrosis. One death caused by skull base collapse and spinal cord impingement as a result of massive osteolysis of the first vertebra and skull base has been reported (2). Spleen lesions appear as variablesized cysts, from millimeters to centimeters. On sonograms, welldefined hypoechogenic masses with occasional internal septations and intralocular echogenic debris can be seen. On computed tomography (CT) scanner, they are seen as single or multiple thin walled, low-attenuation masses with sharp margins that are typically subcapsular in location. No significant contrast enhancement is seen. MRI is the most reliable diagnostic modality for detecting both soft tissue and bony lesions. Lymphatic vascular channels had mostly low signal on T1-weighted sequences and high or isosignal intensity on T2-weighted images. Some had high signal on T1 presumably because of high protein, fat, or blood content (3). Küpeli et al. recommend the surveillance of these lesions without treatment (4). Disseminated pulmonary lymphangiomatosis (DPL) is characterized primarily by multifocal proliferation of pulmonary lymphatic vessels and increased number of complex

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anastomosing channels. These channels tend to dilate with time. This is the only affection considered as a proliferative disease as compared with other lung lymphatic pathologies such as lymphangioleiomyomatosis, lymphangiectasia and lymphangiomas. Patients often present with dypsnea and wheezing, which may be misdiagnosed as asthma. Chest radiographs often show bilateral interstitial infiltrates with pericardial or pleural effusions. This disease evolves and progressively new interstitial infiltrates appear on X-rays. CT scanner evokes the diagnosis by revealing sub-pleural thickening of the interlobular septas and peribronchovascular spaces, a parahilar and mediastinal thickening of liquid density (due to a lymphatic proliferation and excess of lymph) and a bilateral pleural effusion which is sometimes associated with pleural calcifications (5). The diagnosis of certainty of DPL is based on pathological analysis. It defines itself histologically by a diffuse proliferation of lymphatic vessels and smooth muscle in the lung, in the pleural and the mediastinal lymphatic territories. On macroscopic examination of the lung slices, the pleura, the bronchovascular axes and the interlobular septas are all thickened. Immunohistochemical studies reveal the phenotype of the lymphatic cells as being endothelial with a positive response to the vascular markers. The spindle-shaped stromal cells coexpress vimentin, desmin and actin (6). The prognosis for lymphangiomatosis is usually poor, particularly among patients with pulmonary involvement and chylothorax. The natural history tends to be that of slow progression with recurrent chylous accumulations and associated mediastinal compression. The main cause of death in most patients is respiratory failure secondary to infections and rapid chylous accumulation.

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Patients with recurrent chylothorax may benefit from a mediumchain triglyceride and high protein diet. Surgical treatment may be indicated for resection of solitary mediastinal or lung lesions in rare cases. Cases of recurrent thoracic lymphorrhagia and disseminated lymphangiomatosis have been successfully treated with somatostatin. Recurrent chylothorax can be treated with percutaneous drainage and pleurodesis with talc or bleomycin. Interferon-α therapy has been used with limited success. Significant clinical and radiologic improvement of a 3-year-old patient with disseminated lymphangiomatosis after 1 month of treatment using recombinant interferon-α-2b has been reported. Three patients with extensive thoracic lymphangiomatosis have been successfully treated with irradiation (7). DIC is a hemorrhagic syndrome characterized by the disappearance of fibrinogen in the circulating blood. This has been reported previously with or without associated splenic lymphangiomatosis. The literature reports that this coagulopathy is rare and the mechanism is poorly understood. It may be similar to coagulation abnormalities associated with venous malformations. Decreased fibrinogen, increased DDimers and soluble fibrin complex without severe thrombocytopenia have been described in the blood component of these lesions. Eventually, this so-called intravascular coagulation could develop into a systemic disease, giving rise to bleeding due to blood factors consumption and multi-organ failure related to micro-vascular thrombosis (8). Lymphangiomatosis of the spleen can result in splenomegaly with left upper quadrant pain and a risk of bleeding from splenic rupture or consumptive coagulopathy. In these cases, total splenectomy is warranted. Accessory spleens should be removed because they may be a source of disease recurrence. A beneficial effect of partial

splenic embolization to treat disseminated intravascular coagulopathy associated with lymphangiomatosis has been reported. Conclusion DIC in a young child should be investigated. Imaging plays an important role in the determination of its cause. Lytic bone lesions on Xrays associated with affection of soft organs on sonogram or CT should evoke the diagnosis of lymphangiomatosis. Total body MRI enables assessment of lesions in multiple locations. Confirmation is based on pathologic findings. References 1. 2.

Tran D., Fallat M., Buchino J.J.: Lymphangiomatose: A Case Report. South Med J, 2005, 98 (6): 669-671. Aviv R.I., Mchigh K., Hunt J.: Angiomatosis of bone and Soft Tissue: A spectrum of disease from diffuse Lymphangiomatosis to Vanishing Bone Disease in Young Patients. Clin Radiol, 2001, 56: 184190. Chang W.C., Liou C.H., Kao H.W., et al.: Solitary lymphangioma of the spleen: dynamic MR findings with pathological correlation. Br J Radiol, 2007, 80: 4-6. Küpeli S., Araç A., Yalçin B., et al.: Lymphangiomatosis in a child: Eigth years’follow-up without treatment. J Pediatr Hematol Oncol, 2008, 25: 614-619. Yekeler E., Dursun M., Yildirim A., Tunaci M.: Diffuse pulmonary lymphangiomatosis: imaging findings. Diagn Interv Radiol, 2005, 11: 31-34. Ramani P., Shah A.: Lymphangiomatosis. Histologic and immmunohistochemical analysis of four cases. Am J Surg Pathol, 1993, 17: 329-335. Alvarez O.A., Kjellin I., Zuppan C.W.: Thoracic lymphangiomatosis in a child. J Pediatr Hematol Oncol, 2004, 26: 136-141. Mazoyer E., Enjoras O., Laurian C., et al.: Coagulation abnormalities associated with extensive venous malformations of the limbs: differeciation from Kasabach-Merritt syndrome. Clin Lab Haematol, 2002, 24: 243-251.

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STAGE III XANTHOGRANULOMATOUS PYELONEPHRITIS TREATED WITH ANTIBIOTHERAPY AND PERCUTANEOUS DRAINAGE T. Ergun1, A. Akin2, H. Lakadamyali1 Xanthogranulomatous pyelonephritis (XPN) is a rare inflammatory condition usually secondary to chronic obstruction caused by nephrolithiasis and resulting in infection and irreversible destruction of the renal parenchyma. Its standard therapy consists of total or partial nephrectomy. A case of stage III xanthogranulomatous pyelonephritis treated with antibiotherapy and percutaneous drainage is presented in this paper. Key-word: Nephritis.

Xanthogranulomatous pyelonephritis (XPN) is a rare variant of chronic pyelonephritis that is frequently associated with urinary tract obstruction usually caused by nephrolithiasis. Affected cases demonstrate massive renal parenchymal destruction with granulomatous tissue infiltrates containing the lipid-laden macrophages replacing the parenchyma. It is believed that removal of the xanthogranulo matous inflammatory tissue is required for curative therapy. That is why total or partial nephrectomy is recomended for a long-standing mainstay treatment. However, focal XGP cases cured with antibiotherapy alone have also been reported (1-5). This paper presents a stage III xanthogranulomatous pyelonephritis case cured by antibiotherapy and percutaneous drainage. Case presentation A 76-year-old male patient presented to our hospital with the complaint of a right lumbar pain and swelling. His medical history was significant with regard to hypertension and a previous cerebrovascular disease. Physical examination revealed a fluctuating right lumbar mass tender to palpation. The patient’s fever was 36.7 C°, and his urinalysis was normal. The white blood cell count was 14300. Ultrasonography (US) evaluation revealed a giant hyperechoic mass in the right kidney lodge, with a centrally located region of increased echogenity, consistent with acoustic shadowing characteristic for renal

calculi. In addition, a loculated collection containing dense echoes was noticed in the right lumbar region, starting from the subcutaneous area and extending into the right perirenal space. The obtained computed tomography (CT) images demonstrated significant fatty proliferation of the right renal sinus, hilus and perirenal space, focal areas of low density and advanced parenchymal atrophy. The renal contours were preserved. There were central areas of high density and a staghorn calculus. In addition, an anterior displacement of the right colon was noticed due to the space occupying effect of the mass. Besides, a wide collection was observed showing peripheral contrast attenuation and extending from the superior lumbar triangle posteriorly to the subcutaneous tissue, consistent with a perirenal abscess (Fig. 1). The patient was diagnosed with stage III xanthogranulomatous pyelonephritis based on epidemiological properties (advanced age), clinical findings (non-specific and poor symptoms), and CT findings (diffuse atrophic kidney, staghorn stone, low-attenuation parenchymal areas, and widespread perinephritic abscess). In addition, the process was thought to be accompanied by renal replacement lipomatosis, due to observation of significant renal fat proliferation. Antibiotic therapy was initiated (cephasolin and gentamycine), and 2 weeks later a 12F pig-tail catheter was inserted into the abscess cavity under ultrasound guidance. The treatment was continued with cephasolin only following the culture results which indicated

From: 1. Department of Radiology, Alanya Teaching and Medical Research Center, Baskent University School Medicine, Alanya, Turkey, 2. Department of Radiology, Konya Research and Training Hospital, Konya, Turkey. Address for correspondence: Dr T. Ergun, M.D., Baskent University School of Medicine, Department of Radiology, Alanya Teaching and Medical Research Center, 07400 Alanya, Antalya, Turkey. E-mail: tarkanergun@yahoo.com

Staphylococcus aureus growth. Following the drainage procedure, irrigation with saline was done twice daily. The catheter was removed on day 25. No collection was noticed with US in the follow-up visits 2 and 4 months later. The low-density renal parenchymal areas were noticed to have disappeared on the follow-up CT obtained a year later, and no recurrent infection was observed. Discussion XGP is a chronic renal inflammatory disease that arises from an abnormal host response to bacterial infection and results in parenchymal destruction and replacement with lipid-laden macrophages. The most frequently encountered infecting agents (59-95%) are E. Coli and Proteus mirabilis. Gram-positive cocci (especially Staphylococcus aureus), Klebsiella species and Pseudomonas species have also been isolated from urinalyses (6). The main predisposing factors for XGP development are obstruction and genito-urinary system infections. Stone-related obstructions comprise 38-83% of the XGP cases. In addition, diabetes mellitus, lipid metabolism abnormalities, lymphatic obstruction, deterioration of the immune system, leukocyte function abnormalities, malignancy, renal vein occlusion, long-standing paralysis, alcohol, malnutrition, hyperparathyroidy, and renal transplantation are factors that have been described to be weakly corelated with XGP (6-8). XGP usually affects adults age 50 and above. However, the condition has been described in all age groups. The age range of reported cases is 21 days to 90 years (1, 9, 10). Male children and female adults are more frequently affected by the disease. The disease is typically unilateral, and may be focal, segmental or diffuse. Rarely, however, it can show bilateral involvement (11). Clinical

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C Fig. 1. â&#x20AC;&#x201D; Axial CT image showing significant fatty proliferation of the right renal sinus, hilus, and perirenal space, focal lowdensity areas (arrowheads) and advanced parenchymal atrophy (A). Central areas of high-density and renal calculi are observable (B). In addition, a broad collection is noticed extending from the right lumbar subcutaneous area into the right perirenal space, demonstrating peripheral contrast attenuation, consistent with abscess (arrows) (C).

findings are usually non-specific and include fever, deteriorated general condition, weight loss, insidious low-back pain, and palpable mass. Laboratory findings usually show leukocytosis. Additionally, elevation of C-reactive protein, erythrocyte sedimentation rate and liver enzymes may be observed. Abdominal CT has been prompted as a good non-invasive diagnostic tool (12). Renal enlargment, calyx dilation, significant cortical thinning, renal stone, and multiple non-homogeneous areas of low-attenuation indicative of abscess and dilated calices are observed in diffuse XGP. In addition, extrarenal XGP extension (to the perirenal space, anterior and posterior pararenal spaces, ipsilateral psoas muscle, the diaphragm, posterior abdominal wall, skin and

bowel wall) and fistula formation are also clearly demonstrated by CT imaging. On the other hand, focal XGP is observed in CT images as a low-density area with no contrast attenuation following intravenous contrast administration. The focal disease can be easily misdiagnosed as a renal tumor. In addition, XGP is sometimes difficult to be differ entiated from hydronephrosis or pyonephrosis, malakoplakia, renal abscess or lymphoma. The basic therapy-determining factor is the stage of the disease. In stage I (20-64%), nephritic XGP, the inflammation is confined to the kidney. In stage II (14-70%), perinephritic XGP, there is involvement of both the kidney and the perirenal area. In stage III (10-36%), as was the case with our patient, involvement of kid-

ney, perirenal area, and diffuse retroperitoneal area is observed (13). Nephrectomy is considered the curative therapy. Total nephrectomy is the most appropriate therapeutic modality for all stages of diffuse XGP, and for stage III focal XGP. On the other hand, segmental resection of the affected kidney may be applied for stage I and II focal XGP cases. However, the present case, and review of the medical literature, are in support of the option of percutaneous drainage and antibiotic treatment for XGP cases. References 1. Hughes P.M., Gupta S.C., Thomas N.B.: Xanthogranulomatous pyelonephritis in childhood. Clin Radiol, 1990, 41: 360-362.

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STAGE III XANTHOGRANULOMATOUS PYELONEPHRITIS — TARKAN et al 2. Rasoulpour M., Banco L., Mackay I.M., Hight D.W., Berman M.M.: Treatment of focal xanthogranulomatous pyelonephritis with antibiotics. J Pediatr, 1984, 105: 423-425. 3. Ramboer K., Oyen R., Verellen S., Vermeersch S., Baert A.L., Verberckmoes R.: Focal xanthogranulomatous pyelonephritis mimicking a renal tumor: CT and MR findings and evolution under therapy. Nephrol Dial Transplant, 1997, 12: 1028-1030. 4. Brown P.S. Jr., Dodson M., Weintrub P.S.: Xanthogranulomatous pyelonephritis: report of nonsurgical management of a case and review of the literature. Clin Infect Dis, 1996, 22: 308-314. 5. Ho C.I., Wen Y.K., Chen M.L.: Xanthogranulomatous Pyelonephritis Successfully Treated with Antibiotics

Only. J Chin Med Assoc, 2008, 71: 643-645. Levy M., Baumal R., Eddy A.A.: Xanthogranulomatous pyelonephritis in children. Etiology, pathogenesis, clinical and radiologic features, and management. Clin Pediatr (Phila), 1994, 33: 360-366. Malek R.S., Elder J.S.: Xanthogranulomatous pyelonephritis: a critical analysis of 26 cases and of the literature. J Urol, 1978, 119: 589-593. Chuang C.K., Lai M.K., Chang P.L., Huang M.H., Chu S.H., Wu C.J., Wu H.R.: Xanthogranulomatous pyelonephritis: experience in 36 cases. J UroI, 1992, 147: 333-336. Hammadeh M.Y., Nicholls G., Calder C.J., Buick R.G., Gornall P., Corkery J.J.: Xanthogranulomatous pyelonephritis in childhood: preoperative diagnosis is possible. Br J UroI, 1994, 73: 83-86.

10. Youngson G.G., Gray E.S.: Neonatal xanthogranulomatous pyelonephritis. Br J UroI, 1990, 65: 541542. 11. Ozcan H., Akyar S., Atasoy C.: An unusual manifestation of xanthogranulomatous pyelonephritis: bilateral focal solid renal masses. AJR, 1995, 165: 1552-1553. 12. Goldman S.M., Hartman D.S., Fishman E.K., Finizio J.P., Gatewood O.M., Siegelman S.S. CT of Xanthogranulomatous Pyelonephritis: Radiologic-Pathologic Correlation. AJR, 1984 May, 142: 963-969. 13. Dunnick N.R., Sandler C.M., Amis E.S., Newhouse J.H. Renal inflammatory disease. In: Dunnick N.R., Sandler C.M., Amis E.S., Newhouse J.H., eds. Textbook of uroradiology. 2nd ed. Baltimore: Williams & Wilkins, 1997, pp 163-189.

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CONSERVATIVE SURGERY FOR LEFT-SIDED ISOLATED TUBAL TORSION IN PREGNANCY A. ten Cate1, S. Han1, A.-S. Vliegen2, L. Lewi1, J. Verhaeghe1, F. Claus2 We report a case of severe lower abdominal pain in a pregnant woman at 35 weeks and 4 days of gestation. Early diagnosis of an isolated left-sided tubal torsion was established by ultrasound and emergency magnetic resonance imaging (MRI). Subsequent detorsion surgery was able to prevent the need for salpingectomy. The role of emergency imaging and conservative surgery in isolated tubal torsion is discussed. Key-word: Fallopian tubes, torsion.

Case report A 33-year-old patient with an uneventful medical history presented with severe pain in the lower left quadrant of the abdomen at a gestational age of 35 weeks and 4 days. The onset of the pain was sudden and paracetamol was ineffective as pain relief. A few days earlier the patient had experienced a similar pain which had resolved spontaneously. Aside from vomiting, no other complaints were mentioned. There were no signs of obstetric complications. On clinical examination there was a localized tenderness and rebound sign in the lower left quadrant. All biochemical results, including a complete blood count, CRP and urine analysis, were within normal range. Ultrasound examination showed a cystic lesion of 4.4 centimeter situated on the left side lateral of the uterus. MRI was performed for further characterization of the cystic lesion. T2-weighted images showed a segmental dilation of the distal left tuba in proximity of the normalappearing ipsilateral ovary and sigmoid colon (Fig. 1). No signs of hemorrhage were detected on the T1-weighted images. The radiologic diagnosis of an isolated fallopian tubal torsion or torsion of a (para)tubal cyst was suggested. Labor was induced with vaginal application of Dinoproston. After 12 hours a cesarean section was performed because of persistent pain, unresponsive to tramadol, in absence of cervical dilatation. A healthy boy was born. Subsequent inspection of the abdomen showed an edematous and purple left fallopian tube. A threefold torsion

Fig. 1. â&#x20AC;&#x201D; Transabdominal sonographic image (upper left) and T2-weighted magnetic resonance images (clockwise starting from upper right: axial, coronal and sagittal view) of the segmental dilation (white arrow) of the distal left tuba. Note the close proximity of the normal-appearing sigmoid colon (asterix) and ipsilateral ovary (arrowhead).

around its long axis was observed. The tubal fimbriae were also purple and enlarged (Fig. 2A). The contralateral tuba as well as both ovaries appeared normal; no paratubal cysts were present. A normal position of the fallopian tube was reestablished

From: 1. Department of Obstetrics and Gynecology, 2. Department of Radiology, University Hospital Leuven, Leuven, Belgium. Address for correspondence: Dr F. Claus, M.D., Dienst Radiologie UZ-Leuven, Herestraat 49, B-3000 Leuven, Belgium. E-mail: filip.claus@uzleuven.be

via detorsion and prompt revascularization occurred (Fig. 2B). The postoperative recovery was uneventful and no further pain occurred. Discussion Isolated tubal torsion is a rare cause of lower abdominal pain, affecting women in their reproductive age. The incidence in nonpregnant women is estimated at one in 1.5 million (1). In pregnancy, only nineteen cases of isolated fallopian

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Fig. 2. â&#x20AC;&#x201D; A: At laparotomy, inspection of the abdomen showed an edematous and purple left fallopian tube. A three-fold torsion around its long axis was seen (white arrow). The tubal fimbriae were also purple and enlarged (asterix). B: A normal position of the fallopian tube was reestablished and prompt revascularization occurred.

tubal torsion have been described in the literature (1). Several risk factors for tubal torsion have been proposed, such as anatomical abnormalities (e.g. adhesions, previous pelvic surgery, neoplasms, hydro- or pyosalpinx or paratubal cysts), physical conditions (abnormal tubal or intestinal peristalsis, muscular spasms or enlarged hyperstimulated ovaries), hemodynamic abnormalities (venous congestion) and trauma (2, 3). Pregnancy increases the risk of tubal torsion, especially in advanced gestational age, due to changed anatomical position of the uterus and adjacent adnexa (1, 4). The clinical presentation of a tubal torsion is abdominal lower quadrant pain, with or without radiation to the flank. Nausea, vomiting, dysuria and mild vaginal bleeding can be associated. Laboratory results are often normal in the early stage, but leucocytosis, fever and peritonitis may be present in cases complicated by necrosis (3). Ninety percent of the cases published in literature are right-sided tubal torsion, which is hypothesized to be due to the presence of the sigmoid on the left side of the uterus. Diagnosis is difficult due to the nonspecific clinical presentation and normal laboratory findings at early

stages (3). Sonographic findings are the presence of a cystic lesion, adjacent to a normal ovary, both morphologically and on Doppler flow. In case ultrasound is non-diagnostic, MRI is the imaging modality of choice for further work-up of abdominopelvic pathology in pregnant women (5). By combining an excellent soft tissue contrast with a large field of view, MRI allows to further differentiate cystic lesions and examine their relationship with intestinal and internal genital structures. The combination of preoperative imaging by ultrasound and MRI can successfully diagnose a tubal torsion (6). Surgical intervention is necessary for detorsion of the fallopian tube. Early diagnosis and timely surgical intervention can prevent irreversible damage to the fallopian tube and may thereby prevent salpingectomy (4). To our knowledge this is the first pregnant case reported in the literature for which conservative surgery was performed. Detorsion of the fallopian tube by laparoscopy should be considered until a gestational age of 32-34 weeks. In more advanced gestational age the preferred method of intervention is laparotomy, which allows immediate delivery of the fetus by cesarean

section. In absence of necrosis of the fallopian tube, fetal and maternal outcome are good. References 1.

Origoni M., Cavoretto P., Conti E., Ferrari A.: Isolated tubal torsion in pregnancy. Eur J Obstet Gynecol Reprod Biol, 2009, 146: 116-120. Comerci G., Colombo F.M., Stefanetti M., Grazia G.: Isolated fallopian tube torsion: a rare but important event for women of reproductive age. Fertil Steril, 2008, 90: 1198-1115. Krissi H., Shalev J., Bar-Hava I., Langer R., Herman A., Kaplan B. Fallopian tube torsion: laparoscopic evaluation and treatment of a rare gynecological entity. J Am Board Fam Pract, 2001, 14: 274-277. Orazi C., Inserra A., Lucchetti M.C., Schingo P.M.: Isolated tubal torsion: a rare cause of pelvic pain at menarche. Sonographic and MR findings. Pediatr Radiol, 2006, 36: 1316-1318. Wieseler K.M., Bhargava P., Kanal K.M., Vaidya S., Stewart B.K., Dighe M.K.: Imaging in pregnant patients: examination appropriateness. Radiographics, 2010, 30: 12151229. Park B.K., Kim C.K., Kim B.: Isolated tubal torsion: specific signs on preoperative computed tomography and magnetic resonance imaging. Acta Radiol, 2008, 49: 233-235.

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TAKOTSUBO CARDIOMYOPATHY OR APICAL BALLOONING: A CASE REPORT AND A SHORT LITERATURE STUDY T. De Beule1, L. Ardies1, M. De Booij2, E. Janssens1, P. Vanhoenacker1 Takotsubo cardiomyopathy is an important differential diagnosis in patients with an acute coronary syndrome. This syndrome is typically characterized by a reversible contractile dysfunction of the left ventricular myocardium without any obstructive etiological coronary disease. This is not a rare entity in acute settings and a better knowledge of the syndrome could result in a heightened alertness and a higher detection. We present a case of takotsubo showing the importance of cardiac MRI in the differential diagnosis and reviewed the present literature concerning this syndrome and the usefulness of MRI in the detection. Key-word: Heart, diseases.

Transient left ventricular apical ballooning is an acute reversible heart syndrome also named takotsubo cardiomyopathy. The characteristic appearance consists of a round bottom and narrow neck on the end systolic ventriculogram resulting from a regional wall motion abnormality that extends beyond a single coronary vascular bed (1, 2). This syndrome is defined by the clinical sudden onset of acute chest pain simulating an acute myocardial infarction often induced by a psychologic stressor. However, the major difference between takotsubo and an acute myocardial infarction consists of a lack of significant coronary stenosis in takotsubo. This chest pain is accompanied by ST-T changes on electrocardiography and minimal raise of the cardiac enzyme concentration in the peripheral blood (3). Takotsubo is predominant in women and often triggered by an emotional or physical event (4). The combination of the clinical syndrome comparable to acute myocardial infarction, minimal raise in cardiac enzymes and the reversible apical hypokinesia extending the normal vascular territories should raise suspicion for takotsubo (5). The pathophysiologic mechanism is unkown, but catecholamine excess tends to have a central role. The syndrome is not rare, and heightened awareness could likely lead to a higher reported incidence. Case report A 51-year-old Caucasian women presented at the emergency department with a sudden onset of chest

Fig. 1. â&#x20AC;&#x201D; ECG on admission shows ST-elevation in I, II and aVF, which is compatible with an inferior infarction.

pain radiating to the left jaw and a little shortness of breath. In the past few months she consulted for the same clinical problem with no apparent pathological changes, normal ECG and no coronary stenosis. The chest pain was diagnosed as atypical. She was not known to have diabetes and she didn't smoke. Her familial history did not show any significant cardiac conditions. On presentation at the emergency department, her blood pressure was 100/70 mmHg with a heart rate of 100 bpm. Lung auscultation revealed bibasal rales. Electrocardiography showed a sinus tachycardia of approximately 100 bpm (PR interval 146 ms, QRS duration 74 ms, QT/QTc 314/400 ms.) and signs of inferolateral ischemia (Fig. 1). The blood analysis showed

From: 1. Department of Radiology and Imaging, OLV Ziekenhuis, Aalst, Belgium, 2. Department of Radiology, AMC Hospital, Heerlen, The Netherlands. Address for correspondence: Dr T. De Beule, M.D., Dept of Radiology, Olv Ziekenhuis, Moorselbaan 164, B-9300 Aalst, Belgium. E-mail: Tom.debeule@gmail.com

minor changes in the Troponine T concentration and a slight raise of the CK-MB enzymes. Cardiac ultrasound showed apical hypokinesia. Conventional angiography was preformed, revealing no apparent coronary disease or vasospasm. Left ventriculography showed the same apical hypokinesia as seen on ultrasound. An assessment of the myocardial viability was done by performing a cardiac MRI. Cine MRI sequences (steady state free precession pulse sequence) revealed circumferential hypokinesis of the apex with normal contraction of the cardiac base (Fig. 2, 3). This image is characteristic for the previous described apical ballooning cardiomyopathy. Perfusion image after intravenous administration of gadolinium showed no apparent delayed enhancement (Fig. 4) which would be suggestive of myocardial infarction. Our patient improved symptomatically with diuretics and after 4 days no apparent symptoms were noticeable. Control was performed

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Fig. 2. —Left ventricle in systolic phase of the cardiac cycle which reveals a hypocontractility of the left ventricular apex (arrow) and a normal contraction of the base (striped arrow). Cine MRI sequence with SSFP.

which showed improvement of the apical contractility. After one week the patient could be discharged from the hospital. Discussion Takotsubo cardiomyopathy is a recently recognized entity which mimics acute coronary syndrome. Transient left ventricular apical ballooning or Takotsubo syndrome has first been reported in the Japanese literature in 1991 (1, 2). This syndrome characterized by sudden onset of chest pain and ecg-changes mimicking an acute myocardial infarction but with a major difference in the regional wall hypokinesia encompassing multiple vascular territories. Most patients present with chest pain or dyspnoea but the clinical presentation can range from these mild symptoms to rare hemodynamic compromise. However the long term prognosis is much better than that of a traditional acute coronary symdrome (6). Takotsubo is a Japanese word referring to a trap with a round bottom and a narrow neck used for catching octopuses in Japan. The LV morphological features resemble this takotsubo trap (7). The morphology is a typical result of the apical hypokinesia which causes a ballooning of the apex. Other suggested names are ‘transient ventricular ballooning syndrome,’ ‘left ventricular apical ballooning,’ ‘stress-induced cardiomyopathy,’ ‘ampulla cardiomyopathy,’ and ‘broken heart syndrome.’ Recently a new atypical form of takotsubo has been described (8). This variant consists of a hypokinesia of the base or middle

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Fig. 3. — A 4-chambre view of the heart (SSFP cine MRI) in the diastolic phase of the cardiac cycle, which shows no diastolic dysfunction.

Fig. 4. — Delayed enhancement sequence revealing no enhancement.

segment of the myocardium with normal contractility of the apex. In general, a prevalence of 1,22,0% among patients with acute coronary syndrome has been reported (9, 10). Most patients tend to be female and post-menopausal. The age ranges from the first decade until the ninth decade (5). The typical clinical presentation of takotsubo, mimicking an acute myocardial infarction, results in an underestimation of the disease. With a raised awareness for the syndrome and an implementation in the differential diagnosis of an acute coronary syndrome, a higher prevalence is suspected. In most of the cases patients present with chest pain (70-90%) or with less common symptoms such as dyspnea or pulmonary edema. A striking presentation can be cardiac arrest or cardiac shock, but these remain very rare (5, 11). The electrocardiogram at presentation shows ST-segment elevation in one third of the patients, most commonly in the anterior leads (10). T-wave inversion and non-specific ST-elevation can also be recognized. Pathological Qwaves are present in almost 40% of all patients. In serial electrocardiograms a prolongation of QT interval and a T-wave inversion is commonly seen (12). However, torsade the pointes is rarely reported despite the prolongation in QT-interval (13). Cardiac biomarkers of myonecrosis are generally slightly elevated at the time of presentation. This is almost always the case for troponin. Elevation of NT-pro BNP is almost always seen, resembling the extend of the disease. When a more extensive part of the myocardium is aki-

netic, a larger drop in ventricle output can be expected and the atrium will suffer from a heavier afterload. The concentration can be correlated with the outcome of the disease. Coronary angiography is frequently normal or reveals only mild abnormalities. These patients generally do not have obstructive or instable coronary lesions (6). Almost all patients recover fully and the compromised LV-systolic function improves rapidly over a short period of time. The underlying cause of takotsubo remains unkown. However the available studies show that the disease results from extreme emotional and/or physical stress combined with a strong predominance in postmenopausal women (14). A few pathophysiological mechanisms have been proposed. Almost all patients presenting with Takotsubo do not have relevant coronary artery obstruction. Therefore, a concept of epimyocardial spasm was proposed. However, in takotsubo there is no regional wall motion abnormality corresponding to vascular territories. In a study, Gianni et al. found that only few patients experienced multivessel spasms even after using provocative tests (15) Concepts like microvascular disturbance and catecholamine-trigged myocyte injury have been proposed (16). An important imaging modality to differentiate the clinical presentation of takostubo with other aetiologies, such as myocardial apical infarction, or myocarditis is cardiac MRI (17). Delayed hyperenhancement is known to detect myocardial fibrosis and myocardial inflammation and therefore it is typically used for

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examining the extent of myocardial infraction or myocarditis. Myocardial fibrosis develops after a myocardial infarction and the delayed enhancement (DE) area is typically distributed corresponding to a vascular territory. Another important differential diagnosis, myocarditis, can be ruled out in this way by using DE. Patchy areas of delayed enhancement can be seen in 88% of the patients with proven myocarditis (17). Delayed enhancement is virtually absent in takotsubo cardiomyopathy. However, the lack of hyper enhancement itself is not sufficient for diagnosing takotsubo, because in a minority of patients with infarction no apparent enhancement is seen. Second, Cine MRI sequences (steady state free precession pulse sequence) can provide an insight in the typical hypokinesia/akinesia of the myocardium and have the advantage of detecting major complications such as thrombus or aneurysmal dilatation of the ventricular apex. Conclusion Takotsubo cardiomyopathy is an important differential diagnosis of an acute coronary syndrome. Characterized by normal or nearnormal coronary arteries and regional wall abnormalities extending beyond the vascular territories, this syndrome generally has a favorable prognosis. MRI can help in the differential diagnosis between other etiologies of an acute coronary syndrome. Myocarditis and acute myocardial infarction can be ruled out by using the delayed enhance-

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ment sequence. The cine sequences can confirm the regional wall motion abnormality specific to takotsubo. References 1. Dote K., Sato H., Tateishi H., et al.: Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol, 1991, 21: 203-214. 2. Satoh H., Tateishi H., UchidaT.: Takotsubo type cardiomyopathy due to multivessel spasm. Clinical aspect of myocardial injury: From ischemia to heart failure. 1990: 56-64. 3. Desmet W.J., Adriaenssens B.F., Dens J.A.: Apical ballooning of the left ventricle: first series in white patients. Heart, 2003, 89: 1027-31. 4. Gianni M., Dentali F., Grandi A.M., Sumner G., Hiralal R., Lonn E.: Apical ballooning syndrome or takotsubo cardiomyopathy: a systematicreview. Eur Heart J, 2006, 27: 1523-9. 5. Tsuchihashi K., Ueshima K., Uchida T., et al.: Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiology, 2001, 38: 11-18. 6. Parodi G., Del Space S., Carrabba N., et al.: Incidence, clinical findings, and outcome of women with left ventricular apical ballooning syndrome. Am J Cardiology, 2007, 99: 182-185. 7. Kawai S., Suzuki H., Yamaguchi H., et al.: Ampulla cardiomyopathy (Takotsubo cardiomyopathy): reversible left ventricular dysfunction with STsegment elevation. Jpn Circ J, 2000, 64: 156-159. 8. Haghi D., Fluechter S., et al.: Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute apical ballooning syndrome. Int Journal of Cardiology, 2007, 120: 205-211.

9. Stollberger C., Finsterer J., Schneider B.: Tako-tsubo-like left ventricular dysfunction: clinical presentation, instrumental findings, additional cardiac and non-cardiac diseases and potential pathomechanisms. Minerva Cardioangiol, 2005, 53: 139-145. 10. Bybee K.A., Prasad A., Barness G.W., et al.: Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome Am J Cardiol, 2004, 94: 343-346. 11. Bahlmann E., Krause K., Haerle T., van der Schalk H., Kuck K.H.: Cardiac arrest and successful resuscitation in a patient with Takotsubo cardiomyopathy. Int J Cardiol, 2008, 130: e4-6. 12. Matsuoka K., Okubo S., Fujii E., et al.: Evaluation of the arrhythmogenecity of stress-induced tako-tsubo cardiomyopathy from the time course of the 12-lead surface electrocardiogram. Am J Cardiol, 2003, 92: 230-233. 13. Elkhateeb O.E., Beydoun H.K.: Recurrent long QT syndrome and syncope in transient apical ballooning syndrome. Can J Cardiol, 2008, 24: 917-919. 14. Wittstein I.S., Thiemannv D.R., Lima J.A., et al.: Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med, 2005, 352: 539-548. 15. Gianni M., Dentali F., Grandi A.M., et al.: Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J, 2006, 27: 2907-2908. 16. Nef H.M., Möllmann H., Elsässer A.: Takotsubo cardiomyopathy (apical ballooning). Heart, 2007, 93: 13091315. 17. Scholte A.J., Bax J.J., Stokkel M.P., et al.: Multimodality imaging to diagnose takotsubo cardiomyopathy. J Nucl Cardiol, 2006, 13: 123-126.

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IMAGES IN CLINICAL RADIOLOGY Solitary osteochondroma: spontaneous regression F.C. Deprez, M. BeltrĂĄn-MarĂn, J. Malghem, R. Menten, P. Clapuyt1 A 15-year-old female had been followed in our department of pediatric radiology since the age of 11, in order to control a solitary osteochondroma (exostosis) of the right distal femur. Radiographs of the right distal femur (face-profile) and high frequency ultrasound studies (12-5 MHz) of this area were performed to assess the size of the lesion and the thickness of the cartilaginous cap. Follow up of the lesion showed an increase in size from the age of 11 to the age of 12 with a a cartilaginous cap thickness of 3 mm. Coincident with a growth plate closure a thinning of the cartilaginous cap was documented by ultrasounds, reducing from 3 mm to < 1 mm at the age of 13 (Fig. C. Cartilaginous cap of the osteochondroma at the age of 12 - C1 - and 15 years - C2). A spontaneous regression of the osteochondroma occurred in the following years ranging from the age of 13 (Fig. A) to the age of 15 (Fig. B).

Comment Osteochondromas, or exostoses, are the most frequent benign bone tumors in children. Osteochondromas are histologically characterized by a cartilage-caped bony outgrowth, developed on the metaphyses of long bones. Osteochondromas can be isolated (85%) or multiple (15%, in autosomal dominant hereditary osteochondromatosis). Spontaneous regression of osteochondroma is well known but B very rare. It can be observed with sessile or pediculated osteochondromas. Mechanisms of osteochondromas regression remain unknown. The period of resolution ranges from 6 months to 6 years, and always seems to occur before the end of the patient growth. Some authors suggest that tumour could be progressively incorporated into the cortex after the end of its growth, others suggest that it could be an active process of resorption and metaphyseal remodeling. Post-traumatic or micro-traumatic remodeling could equally play a role. At our knowledge, it is the first case reporting a decrease in thickness of the osteochondroma cartilage cap preceding the osteochondroma regression. Dahlin pointed out that an osteochondroma that has stopped growing has practically no cartilage in his cap. Since osteochodroma growth is due to endochondral ossification on the basal surface of hyaline cartilage cap, spontaneous involution of this cap could logically be necessary for the end of the C tumour growth, and eventually for the tumour involution, but is probably not a sufficient condition to explain the regression of the osteochondroma. We would like to remember that ultrasound is the easiest and the cheapest way to assess and follow the thickness of an osteochondroma cartilage cap, especially in the pediatric population. For information, the first case of spontaneous regression of an osteochondroma was described in 1835 by Hunter, and the first report in the PubMed database was done in 1960 by Sellink J.L., in J Belge Radiol, 43: 177-9. Reference 1.

Valdivielso-Ortiz A., Barber I., Soldado F., Aguirre-Canyadell M., Enriquez G.: Solitary osteochondroma: spontaneous regression. Pediatr Radiol, 2010, 40: 1699-1701.

1. Department of Radiology, Cliniques Universitaires St-Luc, Brussels, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Multicentric carpal-tarsal osteolysis J. Peeters1, F.M. Vanhoenacker1,2, G. Mortier3, P.M. Parizel1 A 2.5-year-old girl presented with pain and reduced strength in hands and wristsand walking difficulties. Clinical examination revealed a position deformity of both hands and broad elbows with limited extension. Plain films showed marked changes with a rather symmetric distribution. Radiograph of the left hand revealed absence of ossification of carpal bones with shortening of the wrist (Fig. A, long arrow). Ulnar deviation of the wrist was seen due to erosion and shortening of the ulna (Fig. A, short arrow). The proximal ends of the second and third metacarpal were tapered (Fig. A, curved arrows). An oblique radiograph of the right foot showed underdeveloped medial tarsal bones (Fig. B, arrow). A lateral radiograph of the right elbow demonstrated irregular delineation of the capitulum of the humerus (Fig. C, arrow). Based on the combination of clinical and imaging findings, the diagnosis of multicentric carpal-tarsal osteolysis (MCTO) (MIM 166300) was made.

Comment MCTO is a rare congenital osteolysis syndrome. There are two major subtypes: with or without nephropathy. It is considered as an autosomal dominant condition for which the gene defect remains unravelled. The pathogenesis is still a matter of debate, but abnormal proliferation of fibrous tissue or an immune disturbance have been incriminated as potential etiologic mechanisms. Histological evidence of active inflammation has never been shown. The onset of MCTO may be exacerbated by a mild trauma. The disorder has a characteristic clinical course and begins in childhood with joint pain, swelling and tenderness. In order of frequency, the carpal bones, tarsal bones and other joints (elbow and shoulder) are involved to a variable degree. The involvement may be asymmetric. Typically, in adolescence the symptoms subside with a relatively asymptomatic period. Progressive deformities develop in the third decade. Affected individuals may have a triangular face with mandibular hypoplasia. In some patients nephropathy can occur and may be fatal. Plain radiographs have a pivotal role in the diagnosis of the disease. The radiological hallmark consists of progressive osteolysis of the carpal and tarsal bones. In early stage disease, there is progressive demineralization with loss of bone contours. Further bone resorption results in collapse, fragmentation and sclerotic remnants of the carpal and tarsal bones. Finally, partial resorption of adjacent tubular bones leads to tapering of the proximal ends of the metacarpals and metatarsals with a characteristic “sucked candy” appearance. In severely affected individuals deformity of metacarpal, metatarsal and interphalangeal joints may occur. Irregular delineation of the epiphyseal centers of elbow and shoulder may occur as well. On magnetic resonance imaging, a fibro-collagenous tissue replaces the carpal or tarsal bones, without evidence of synovial inflammation. The most significant differential diagnosis includes juvenile rheumatoid arthritis (JRA). MCTO can be clinically differentiated from JRA by absence of parameters of acute inflammation. MCTO is distinguished from Gorham’s osteolysis in that the latter is unicentric and histopathologically associated with hemangiomatosis. Our patient was treated supportively, with physiotherapy and ergotherapy. There is little evidence suggesting that bisphosphonates may retard the natural history or progression of the disease. Hemodialysisis applied in case of endstage renal failure complicating the subtype with nephropathy.

C Reference 1.

McDonald K., Toms A.P., Armon K., Johnson K., Marshall T.J.: Carpal-tarsal osteolysis with elbow involvement. Skeletal Radiol, 2007, 36: 1097-1101. 1. Department of Radiology, University Hospital Antwerp, UZA, University of Antwerp, 2. Department of Radiology, AZ Sint-Maarten, Duffel-Mechelen, Duffel, 3. Department of Medical Genetics, University Hospital Antwerp, UZA, University of Antwerp, Edegem, Belgium.

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IMAGES IN CLINICAL RADIOLOGY Ossification of the ligamentum flavum in the cervical spine L. Dewachter, D. Violon, I. Crevits1 A 67-year-old Caucasian woman with no medical history was referred to the hospital with severe neck pain radiating to the left arm. A plain X-ray and non enhanced CT scan of the cervical spine was performed. CT scan (Fig. A, B) revealed a dorsolateral V-shaped hyperdensity in the spinal canal at the level of the ligamentum flavum at C6 level with narrowing of the vertebral canal and compression of the spinal cord. In retrospect the plain X-ray (Fig. C) showed two nodular opacities projecting posterior on the cervical canal. These imaging findings were diagnostic for an ossification of the ligamentum flavum.

Comment Ossification of the ligamentum flavum (OLF) usually occurs in the lower thoracic and lumbar spine and is uncommon in the cervical spine. The relative incidence of OLF in the cervical spine is approximately 0.9%. It is usually seen in East Asian populations and exceptionally reported in Caucasian people. OLF can be isolated or it can be associated with degeneration of other osseous ligaments of the vertebral column such as ossification of the posterior longitudinal ligament (OPLL) and diffuse idiopathic skeletal hyperostosis (DISH). The etiopathogenesis remains unclear. Some have correlated it to systemic diseases (diabetes mellitus, haemochromatosis, fluorosis and disorders of calcium and phosphorus), others have highlighted the importance of repeated mechanical stress causing degeneration and ossification. Symptomatology involves neck or back pain, sensory disturbance of upper and lower extremities, numbness, gait disturbance and tetraparesis. CT remains the investigation of choice to demonstrate ossification as a “V”shaped hyperdensity. MRI and particularly T2-weighted images are useful in showing the degree and extent of spinal cord compression. On MRI the ossified ligamentum flavum appears as a linear or nodular hypo-intens lesion posterior to the thecal sac on both T1 and T2-weighted images. It is therefore indicated to combine CT and MR imaging. The treatment of choice is a posterior decompressive laminectomy with removal of the thickened, ossified ligament. Prognosis is good, depending on the severity of myeolopathy, with a neurological improvement in most operated patients. This is an exceptional case because our patient is Caucasian, the ossification is present at cervical level and is symptomatic. References 1.

Kim K., Isu T., Nomura R., Kobayashi S., Teramoto A. Cervical Ligamentum Flavum Ossification. Two case reports. Neurol Med Chir, 2008, 48, 183-187. 2. Kruse J.J., Awasthi D., Harris M., Waguespack A. Ossification of the Ligamentum Flavum as a Cause of Myelopathy in North America: Report of Three Cases. J Spinal Dis, 2000, 13: 22-25.

1. Department of Radiology, Heilig-Hart ziekenhuis, Roeselare-Menen, Belgium.

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JBR–BTR, 2011, 94: 220.

IMAGES IN CLINICAL RADIOLOGY Mondor’s disease of the breast A.S. Celebi, A. Ozel, A. Bayram1 A 34-year-old woman, who has a positive family history for breast cancer, presented with a palpable, painful cord associated with a skin discoloration on her left breast. Physical examination revealed palpable cord-like structure with localised tenderness in the left breast at twelve o’clock position. MLO mammography showed a superficial tubular density in the superior aspect of the left breast (arrow). Anterior to the tubular density, there was a minimal focal skin thickening (Fig. A). Ultrasonography also showed skin thickening and a superficial dilated tubular structure at the palpable site (Fig. B). On color Doppler examination, no flow was detected in the tubular structure. The diagnosis of Mondor’s disease of the breast was made on the basis of clinical findings and radiologic imaging findings. She was treated symptomatically with antiinflammatory and analgesic drugs. The symptoms resolved after a 6-week follow up. On follow-up sonography, the decrease in calibration of the thrombosed vein and recanalisation on color Doppler is seen (Fig. C). Comment

Mondor’s disease of the breast is a benign condition characterised by superficial thrombophlebitis of the mammary region. Clinical manisfestation of this disease includes a palpable cord or a mass in the breast, usually associated with pain and skin discoloration. The risk factors reported for the development of this condition are breast surgery, breast biopsy, inflammatory process, breast cancer and trauma. Mammography usually reveals the linear densities that represent the thrombosed vein. At ultrasonography, the thrombosed vein appears as a tubular structure that does not show any flow on color Doppler. Mondor’s disease is a self limiting condition treated conservatively with antiinflammatory and analgesic drugs. Because of the reported association of breast cancer with Mondor’s disease, mammography is strongly recommended. The radiologists should be aware of the radiological findings of this disease to reach the correct diagnosis and to exclude an associated breast cancer. Reference 1.

Shetty M.K., Watson A.B.: Mondor's disease of the breast: sonographic and mammographic findings. A JR, 2001, 177: 893-896.

1. Department of Radiology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

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JBR–BTR, 2011, 94: 221.

IMAGES IN CLINICAL RADIOLOGY Reversible splenic ischemia in inflammatory bowel disease S. Van Nieuwenhove, L. Ghijselings, J. Pringot, P. Matthys A 32-year-old man was admitted to the emergency department complaining of abdominal pain, vomiting and fever. In his medical history we noted Crohn’s disease. The laboratory data showed an increased value of CRP (39 mg/l) and leukocytosis at 14800 WBC/µl. There was also mild elevation of transaminases. Abdominal MDCT was performed to detect a complication of the inflammatory bowel disease. The portal venous-phase enhanced CT scan showed wall thickening of the terminal ileum surrounded by some ascitis, compatible with exacerbation of Crohn’s disease. A wedge-shaped hypodense area at the lower posterior part of the spleen was also shown (Fig. A). Careful study of the splenic and superior mesenteric veins revealed a focal filling defect corresponding to splenic and mesenteric venous thrombosis (Fig. B). Consequently, the focal splenic lesion corresponded to splenic hypoperfusion secondary to splenic vein thrombosis in a patient suffering from inflammatory bowel disease. After six weeks anticoagulant treatment, follow-up CT showed that the venous thrombus and the hypodensity of the spleen have disappeared (Fig. C). The diagnosis of reversible splenic ischemia could be made due to the normalization of enhancement on the follow-up MDCT after medical therapy.

Comment

Splenic ischemia has many etiologies including hematologic malignant neoplasms, thromboembolism and vasculitis. It is clinically silent in 30% of cases or is revealed by left upper abdominal pain, chest pain, fever, nausea and vomiting. Splenic ischemia appears as a wedge-shaped region of low attenuation on portal venous-phase enhanced CT. Acute splenic vein thrombosis is one of the causes of splenic ischemia. It is mainly secondary to a prothrombotic state resulting from primary or secondary hypercoagulability disorders, cancer, intra-abdominal infections, post-operative condition, cirrhosis and portal hypertension. In inflammatory bowel disease (IBD) thrombosis has a prevalence of between 1,2-6,1%, most frequently occurring during increased disease activity or during infectious complications. Patients with the disease have a three times higher risk of venous thrombotic events than the general population. Although the pathogenesis is not completely understood, IBD is recognized as being a C hypercoagulable state associated with platelet activation. Thromboembolic events usually occur as deep venous thrombosis or pulmonary embolism, although thromboses have been detected in other regional circulations, including brain, retina, and liver. The diagnosis of venous thrombosis is important to prevent complications requiring surgery such as bowel or venous splenic infarctions. Reference 1.

Miehsler W., et al.: Is inflammatory bowel disease an independent and disease specific risk factor for thromboembolism? Gut 2004, 53: 542-548.

1. Radiology Department, Cliniques de l’Europe, St. Elisabeth, Brussels, Belgium.

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JBR–BTR, 2011, 94: 222.

IMAGES IN CLINICAL RADIOLOGY Hyperostotic meningioma mimicking skull osteoma M. Eyselbergs1,2, F.M. Vanhoenacker1,2, D. Kools3 A 79-year-old female patient was referred to the radiology department because of a slowly enlarging bony mass on her left forehead. Neurological and systemic examinations were otherwise unremarkable. Computed tomography (CT) with bone window settings showed a broad based hyperostotic lesion on the tabula externa of the left frontal bone (asterisk) with associated sclerosis of the diploë (arrowheads) and an irregular delineation of the tabula interna (arrow) (Fig. A). Magnetic resonance imaging (MRI) also showed flat thickening of the dura that was slightly hyperintense to brain parenchyma on FLAIR (Fig. B, arrow). T1-weighted imaging (WI) after gadolinium contrast administration clearly revealed enhancement of the thickened dura adjacent to the skull lesion (Fig. C, arrow) and confirmed the overlying sclerosis (arrowhead) and hyperostosis (asterisk) depicted on CT. The imaging features were compatible with findings of meningioma en plaque (MEP). Resection of the tumor was performed with subsequent duraplasty and cranioplasty. Histological examination confirmed the MEP arising from arachnoid meningoendothelial cells.

Comment Meningioma is the most frequently observed intracranial non glial tumor in the adult population (20%) with a female predominance. The tumor arises more frequently in African-Americans. Approximately 10% of the meningiomas are clinically silent. Typically, this tumor is slowly growing, sharply demarcated and surrounded by a capsule. Two main morphological configurations can be encountered: a spherical lobulated dural based one and a more sheetlike ‘en plaque’ configuration with dural and sometimes overlying bony infiltration. Although hyperostosis is a well known imaging characteristic of most meningiomas, this feature predominates in MEP. Both CT and MRI are useful imaging modalities for diagnosis of MEP. CT with bone window settings often demonstrates adjacent bony involvement such as B erosions, sclerosis and hyperostosis. The degree of hyperostosis is usually disproportionate to the underlying size of the lesion. Sometimes a subdural plaque of ossification can be seen that is separated from the sclerotic or hyperostotic bone by a linear translucency corresponding to dura mater. On MRI the lesion is iso- to hypo-intense on T1-WI and has a variable appearance on T2-WI correlating to pathological features. A cerebrospinal fluid cleft can often be visualized on T2-WI which confirms its primary extra-axial localization. After contrast administration more than 95% of the lesions enhance vividly both on CT as on MRI. Multiple mechanisms are proposed for the hyperostosis associated with meningiomas but tumoral invasion of the overlying bony structures seems to be the most accepted theory. The differential diagnosis of focal or regional skull hyperostosis is extensive and includes benign and malignant lesions. In the benign group, an osteoma must be considered since these neoplasms are the most common primary benign bone tumors in the craniofacial skeleton. However, an osteoma lacks contrast enhancement after contrast administration and normally does not involve the diploë. Other benign lesions consist primarily of fibrous dysplasia, Paget’s disease, calcified cephalo- or subdural hematoma and hyperostosis C interna. Malignant causes of focal skull hyperostosis comprise osteoblastic metastasis and lymphoma. Treatment of choice of symptomatic lesions consists of resection of the meningioma with the associated hyperostotic bone since definite proof of tumoral invasion can only be obtained after careful histological examination. An initial “wait and see policy” may be considered for asymptomatic lesions. Reference 1.

Min J., Kang S., Lee J., Chung Y., Lee H.: Hyperostotic meningioma with minimal tumor invasion into the skull. N eurolM ed Chir, 2005, 45: 480-483.

1. Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, Duffel, 2. Department of Radiology, Antwerp University Hospital, Edegem, 3. Department of Neurosurgery, AZ SintMaarten Duffel-Mechelen, Duffel, Belgium.

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JBRâ&#x20AC;&#x201C;BTR, 2011, 94: 223.

IMAGES IN CLINICAL RADIOLOGY Fast progressive memory loss in a 63-year-old man K. De Smet, M. De Maeseneer, T. Yazdi Amir, J. De Mey1

A 63-year-old man presented to the neurology department with fast progressive memory loss especially short term memory. For 2 weeks he had experienced loss of orientation, judgment difficulties, and concentration problems. A CT scan of the brain was normal. MRI showed normal findings on T1 and T2 weighted images.. There was no contrast enhancement. On diffusion weighted images hyperintense signal was seen at the cortex of the right hemisphere and in the basal ganglia. On PET regional hypometabolism of glucose correlated with sites of increased intensity on diffusion weighted images. An electroencephalogram showed periodic synchronous bi- or triphasic sharp wave complexes. Laboratory findings showed a positive CSF 14-3-3 immuno-assay. Given these findings the diagnosis of sporadic Creutzfeldt-Jacob disease was suggested. Dementia progressed rapidly and the patient subsequently developped myoclonic jerks. The patient died of pneumonia one month later. Brain biopsy confirmed the diagnosis of Creutzfeldt Jacob. Comment

Creutzfeldt-Jacob disease is a rapidly progressive fatal form of dementia caused by a prion. It is potentially transmittable. Sporadic CJD occurs most commonly in the elderly, Spontaneous CJD occurs throughout the world, and there is no male or female predilection. CJD can be inherited (familial form), sporadic (sCJD), or acquired (nvCJD). The familial form of CJD is related to mutations in the PRPN gene on chromosome 20. Acquired CJD is related to an infection from prion containing materials such as surgical instruments, cadaveric dura mater grafts, EEG electrodes, corneal transplant, and pituitary hormones such as growth hormone. A bovine source can also be a cause (infected beef products). The clinical manifestations differ according to the stage of the disease. At onset there is fatigue, visual disturbance, depression, and insomnia. After a few weeks there is rapidly progressive mental deterioration with dementia. As the disease progresses periodic synchronous discharges occur on the EEG and myoclonus may be evident a quite typical finding in CJD. Death usually occurs within 1 year of onset due to a respiratory tract infection. CSF protein 13-3-3 immunoassay is a useful diagnostic test although this protein may be present in other disorders. A brain biopsy is a highly accurate method of diagnosis. On conventional MR high signal intensity in the cerebral cortex and basal ganglia may be apparent on T2 weighted images. Nevertheless with conventional MR imaging findings are difficult to visualize. FLAIR images tend to reveal the cortical abnormalities better. DWI are the cornerstone for early diagnosis of CJD showing areas of high signal in the cortex and in the basal ganglia and thalamus. These imaging findings are accompanied by decreased ADC values suggestive of restricted diffusion within the tissue due to vacuolisation. Differential diagnosis include MELAS, venous hypertensive encephalopathy and chronic herpes encephalitis. At present there is no treatment for CJD but the early changes on DWI may prove very valuable once a treatment becomes available.

1. Department of Radiology, UZ Brussel, Jette, Belgium.

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JBRâ&#x20AC;&#x201C;BTR, 2011, 94: 224.

IMAGES IN CLINICAL RADIOLOGY A male infant presenting with acute urinary retention L.J. De Cocker1, A. Van Baelen2, M. Smet1, L. Breysem1

A 3-month-old male infant was admitted to the emergency department for acute urinary retention. A voiding cystourethrogram was performed because urethral valves were suspected. After bladder catheterization, the plain radiograph prior to filling of the bladder showed an abnormal course of the urinary catheter tip together with focal absence and displacement of bowel gas out of the pelvis. Early contrast opacification of the bladder (Fig. A) demonstrated an abnormal cranial position of the lumen and an extrinsic impression on the bladder base, which became obscured after further distension of the bladder (Fig. B). These findings suggested presence of a pelvic mass, which was confirmed sonographically. CT and MRI were performed for better tumor delineation and tissue characterization. Both demonstrated a sharply delineated presacral soft tissue mass with homogeneous enhancement and DWI showed diffusion restriction. Sagittal T2-weighted image (Fig. C) nicely exhibits upward elevation of the bladder caused by a homogeneous presacral mass. Serum analysis showed increased neuron specific enolase and increased catecholamine metabolites were found in the urine. Tru-cut biopsy specimens confirmed neuroblastoma. CT and MIBG scan revealed no distant sites outside the pelvis while a bone scintigraphy ruled out bone metastases. The tumor was macroscopically completely removed by means of a median laparotomy, and the infant recovered well after therapy. Comment

The two main differentials for a presacral solid mass in an infant are those of a sacrococcygeal teratoma (Altman type IV, i.e. presacral tumor without external extension) and of a pelvic neuroblastoma. Neuroblastoma is the most common extracranial solid tumor in infancy. It arises from neural crest cells and can therefore occur anywhere along the sympathetic chain, however only 5% arise in the pelvic region and urinary retention as presenting symptom is extremely rare. Increased catecholamine metabolites (vanillylmandelic acid [VMA] and homovanillic acid [HVA]) are almost invariably found in the urine. The present case nicely illustrates the value of some imaging signs in conventional radiography. The abnormal distribution of bowel gas and the aberrant position of inserted devices are important signs in recognizing presence of an abdominal mass. This case also stresses the significance of acquiring early filling images during cystography, as findings may become obscured after complete distension of the bladder. Further evaluation of presacral masses depends on CT and MR. These are sometimes performed in combination to obtain superior delineation and improved depiction of various tissue types. The CT and MRI findings of a presacral mass without fatty and cystic components favor neuroblastoma over teratoma, since neuroblastomas do not contain fat. Furthermore neuroblastomas demonstrate in approximately 85% of cases foci of calcifications on CT, and this can be appreciated best on non-enhanced CT scans. On MRI, small neuroblastomas may be homogeneous in appearance with low signal intensity on T1- and high signal on T2-weighted images, and variable contrast enhancement. Larger tumors tend to show more heterogeneous intensities resulting from areas of hemorrhage and necrosis. Viable tumor of neuroblastoma demonstrates restricted water diffusion without exception on initial ADC (apparent diffusion coefficient) map prior to therapy, and DWI therefore has a great potential in the evaluation of early treatment responses in neuroblastoma.

C 1. Department of Radiology, 2. Urology, University Hospitals Leuven, Leuven.

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JBRâ&#x20AC;&#x201C;BTR, 2011, 94: 225.

IMAGES IN CLINICAL RADIOLOGY Oblique meniscomeniscal ligament: a potential pitfall in the diagnosis of knee injury H. Claes1, S. Pans1

A 30-year-old male soccer player presented three years after arthroscopic right anterior cruciate ligament (ACL) repair with complaints of pain and reduced functionality in the right knee. MR imaging obtained on a 3 Tesla scanner showed some fibro-inflammatory tissue on the anterior aspect of the ACL graft and a fissure centered in the femoral trochlear cartilage. Interestingly, a hypo-intense, cord-like structure was visualized running from the posterior horn of the lateral meniscus through the intercondylar notch. On coronal and sagittal images, this structure mimicked a bucket handle tear of the lateral meniscus (double posterior cruciate ligament sign, Fig. A) but if followed closely, passage towards the anterior root of the medial meniscus was noticed. This was best illustrated on the axial images. Preoperative (Fig. B) and postoperative (Fig. C) PD-weighted axial images are shown for comparison. Configuration of the lateral meniscus was normal and no part seemed missing. Some mild degeneration of the posterior horn of the lateral meniscus was present, but no tear was found. The medial meniscus was intact. These findings were compatible with an anatomical variant called the medial oblique meniscomeniscal ligament (OMML). Retrospectively, a much thinner OMML was visible on the preoperative MR images on which the diagnosis of a ruptured ACL was made (Fig. B). Due to postoperative fibrosis, the ligament became thicker and the fibers more separated by hyperintense lines (Fig. C). Coincidentally, the patient recently underwent an MRI examination of the contralateral knee after a soccer injury, where a normal medial OMML was clearly visible. When reviewing the recorded arthroscopic video images of the cruciate ligament surgery three years earlier, the orthopedic surgeon confirmed the presence of this particular ligament. Comment

There are several well-known incidentally found anatomical structures in the knee that can mimic meniscal tears and displaced meniscal fragments and the OMML is but one of these. Other anatomical variants include the meniscofemoral and transverse meniscal ligaments, which mimic meniscal tears at their attachment sites. They require no treatment. A medial and a lateral OMML are known, both running through the intercondylar notch between the cruciate ligaments. They are named by their anterior attachment. The medial OMML attaches to the anterior horn of the medial meniscus and the posterior horn of the lateral meniscus; vice versa for the lateral OMML. Prevalence ranges from 1-4%. It should not be mistaken for a displaced meniscal fragment from a bucket handle or flap tear. Reference 1.

Sanders T.G., Linares R.C., Lawhorn K.W., Tirman P.F., Houser C.: Oblique meniscomeniscal ligament: another potential pitfall for a meniscal tear -anatomic description and appearance at MR imaging in three cases. Radiology, 1999, 213: 213-216.

1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium.

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JBRâ&#x20AC;&#x201C;BTR, 2011, 94: 226.

ABSTRACTS OF PAPERS FOR FULL MEMBERSHIP Detection and characterization of unruptured intracranial aneurysms: comparison of 3T MRA and DSA

Added value of MDCT in the evaluation for coronary artery fistulas

BONE 3T MR arthrography of glenohumeral lesions

B. Mine

Purpose: To compare Magnetic Resonance Angiography (MRA) at 3 Tesla (3T) and Digital Subtraction Angiography (DSA) for the detection and characterization of unruptured intracranial aneurysms (UIA). Material and methods: This study has been approved by our local ethical committee. From February to August 2010, 40 consecutive patients with UIA contemporarily underwent MRA at 3T including time-of-flight (TOF-MRA) and contrast enhanced (CE-MRA) techniques and DSA. MR images were independently reviewed by 3 neuroradiologists and DSA images were reviewed by 2 neuroradiologists together. Interobserver and intertechnique agreements were assessed for aneurysm detection and characterization including maximal diameter, neck width and the presence of a bleb or a branch arising from the sac. Results: DS angiography revealed 56 aneurysms. Mean sensitivity and positive predictive value of MRA were 91.4% and 93.4% respectively. For UIA < 3 mm and those â&#x2030;Ľ 3 mm, MRA had a mean sensitivity of 74.1% and 100% respectively. Intertechnique and interobserver agreements were substantial for the measurement of UIA maximal diameter (mean " = 0.607 and 0.601 respectively) and were moderate and fair for neck width measurement respectively (mean " = 0.456 and 0.285 respectively). For bleb detection, intertechnique and interobserver agreements were fair and slight respectively (mean " = 0.312 and 0.116 respectively) whereas both were slight for detection of branches arising from the sac (mean " = 0.151 and 0.070 respectively). Conclusion: MR angiography at 3T has a high sensitivity for the detection of UIA. However, it remains significantly inferior to DSA for morphological characterization of UIA.

1. Department of Radiology, Erasme Hospital, Brussels, Belgium.

T. Vanderhasselt, K. De Smet, P. Dewachter, K. Tanaka, D. Verdries, J. De Mey1 Objectives: Coronary artery fistulas (CAFs) are rare congenital or acquired coronary anomalies in which blood is shunted into a cardiac chamber or great vessel, thereby bypassing the myocardial capillary network. Correct diagnosis and subsequent surgical correction are of great importance since CAFs predispose for complications, including heart failure or myocardial infarction in young patients. In this review, we want to highlight the added value of MDCT in the diagnosis of these often difficult to detect entities with potentially fatal outcome. Methods: Clinicopathological and imaging features of CAFs are discussed through reviews of the literature and illustrated by images obtained in our own institution. Results: MDCT is a noninvasive and accurate imaging technique for the depiction of major CAFs. Use of multiplanar reformation (MPR) may demonstrate sites of origin and termination of abnormal bloodvessels. MDCT provides highresolution anatomic images showing enlarged CAF and allowing evaluation for aneurysmal dilatation or thrombus formation in the vessel. Volumerendered images help surgeons understand the anatomic complexity before surgery. Conclusion: CAFs are rare cardiac defects, predisposing for potentially letal complications. MDCT is a noninvasive and useful modality for diagnosis of CAFs, allowing for identification of anomalous origin and course of the coronary arteries, assessment of the complexity of the fistula and preoperative evaluation.

1. Department of Radiology, UZ Brussel, Brussels, Belgium.

S. Doering, C. Boulet, M. DeMaeseneer, N. Pouliart, J. de Mey, M. Shahabpour1 Purpose: To describe the normal anatomy, normal variants and pathologic MR arthrographic (MRA) appearance of the superior (SGHL), middle (MGHL) and inferior (IGHL) glenohumeral ligaments and capsulolabral lesions, based on retrospective correlation of MRA findings with detailed arthroscopic descriptions provided by two skilled shoulder surgeons. Methods and Materials: On a series of 500 MRA of the shoulder performed from 1st January 2008 to 15th April 2011, using 3T (277 patients) or 1.5T (223 patients), 102 patients with shoulder instability underwent arthroscopy. MRA included coronal fat-saturated PD and T1W images, axial fat saturated PDW images and sagittal images using dual PD-T2 sequence without fat saturation. The MR findings were retrospectively correlated with arthroscopic descriptions and drawings. Results: Normal anatomy and normal variants of GHL ligaments are illustrated; their knowledge is an important prerequisite for avoiding errors in the interpretation of GHL pathologies. Sprain of SGHL and MGHL, midsubstance tear, avulsion or fibrous thickening of MGHL and IGHL are depicted on MR images using fast spin echo sequences with and without fat saturation and on corresponding arthroscopic views. Other pathological signs are demonstrated as frank discontinuity of MGHL or IGHL, nonvisualisation of IGHL and undulation of SGHL and MGHL. Associated lesions of capsulolabral ligaments are described a well. Conclusion: MR arthrography can be useful for direct visualisation of glenohumeral ligamentous lesions and associated capsulolabral pathologies. Recognition of glenohumeral lesions is very important in the preoperative workup of shoulder instability and trauma. 1. Department of Radiology, Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium.

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JBR–BTR, 2011, 94: 227.

NEWS FROM THE MUSEUM The Royal Belgian Academy of Medicine recently granted Dr R. Van Tiggelen, Curator of the Belgian Museum of Radiology the “Docteur Frans Jonckheere Prize” on the History of Medicine (2008-2010) for his book “A transparent skull. An illustrated history of neuroradiology”.

Saturday September 17, 2011 The Belgian Museum of Radiology celebrates the 100th anniversary of Nobel Prize granted to Marie Curie for her discovery of Radium Place: Universitaire Ziekenhuis Brussel, Dpt of Radiation Therapy and Oncology Oncologisch Centrum Laarbeeklaan 101 1090 Brussel Information: info@radiology-museum.be

CLASSIFIED SERVICES

University Hospital of Mont-Godinne Belgium recruits Radiologists Terms of conditions: – Working time: full time or part time – Status: employee or independent – Skills: polyvalent and/or specialized in general radiology, senology, ultrasound, Doppler/ultrasonography, CT-scanner, NMR (1,5-3T), Pet-CT or Spect-CT For further informations contact: – Pr Patrick De Coster, Medical Director: 081.42.30.00 – patrick.decoster@uclouvain.be or – Dr Michaël Dupont, Medical Chief of Radiology: 081.42.35.17 – michael.dupont@uclouvain.be Please send application with cover letter and resume by post or e-mail to: CHU Mont-Godinne To the attention of Mr Patrick De Coster, Medical director, Avenue Docteur Gaston Thérasse, 1 5530 Yvoir Belgium

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228

ANNOUNCEMENT STUDY GRANTS OF THE BELGIAN SOCIETY OF RADIOLOGY

BEURS VAN DE KONINKLIJKE VERENIGING VOOR RADIOLOGIE

BELGISCHE

BOURSE DE LA SOCIETE ROYALE BELGE DE RADIOLOGIE

Door de KBVR wordt een beurs ten bedrage van € 2975 ter beschikking gesteld aan elk van de 7 universitaire opleidingscentra voor radiologie. Deze zijn: KUL, RUG, VUB, UIA, UCL, ULB, ULg. Deze beurs zal dienen om ofwel de reiskosten te dekken van een studiereis uitgevoerd door één van haar leden ofwel om kosten voor research te dekken uitgevoerd door één van haar leden.

La Société Royale Belge de Radiologie met à la disposition de chacun des 7 centres universitaires de radiologie (KUL, RUG, UCL, VUB, UIA, UCL, ULB, ULg) une bourse d’un montant de 2975 €. Celle-ci est destinée à couvrir les frais de voyage d’étude d’un de ses membres ou à couvrir les frais d’un travail de recherche d’un de ses membres.

Reglement

Règlement

1. Als kandidaat komt in aanmerking iedere arts of doctor in de genees-, heel- en verloskunde die een opleiding volgt of gevolgd heeft tot specialist in de radiologie aan één van de Belgische universiteiten met inbegrip van de hieraan verbonden niet-universitaire stagecentra. De kandidaat moet titulair lid zijn van de KBVR.

1. Sera prise en considération la candidature de tout docteur en médecine, accomplissant ou ayant accompli sa formation de spécialiste en radiodiagnostic dans une université belge ou un centre de stage non-universitaire y attaché. Le candidat doit être membre titulaire de la SRBR.

2. a. Voor de reisbeurs:

2. a) Bourse de voyage :

de kandidaat legt een studieproject voor aan het bureau van de KBVR dat door de titularis van de leerstoel radiologie van zijn universiteit is goedgekeurd. Ingeval de kandidaat een gedeeltelijke of volledige opleiding volgt in één van de niet-universitaire stagecentra dient zijn aanvraag goedgekeurd te worden door zijn stagemeester en de titularis radiologie van de universiteit waaraan het stagecentrum verbonden is of van de universiteit waar de kandidaat zijn einddiploma van doctor in genees-, heel- en verloskunde heeft gehaald. b. Researchbeurs: de kandidaat legt een researchproject voor aan het bureau van de KBVR dat door de titularis van de leerstoel radiologie van zijn universiteit is goedgekeurd. Dit project dient welomschreven te zijn zowel naar inhoud als naar nodige werkingsmiddelen. 3. a. Reisbeurs: als studieprojecten komen bij voorkeur in aanmerking: een verblijf van ongeveer 2 maanden in een buitenlands centrum voor radiologie met het oog op het verwerven of verdiepen van een bijzondere ervaring in één of andere radiologische onderzoeksmethode of met het oog op het verbeteren van de kennissen van de kandidaat in één of ander domein van de radiologie. b. Researchbeurs:

Le candidat déposera un projet d’étude approuvé par le responsable du département de radiologie de son université. Si la formation s’effectue en tout ou en partie dans un centre de stage non-universitaire, la demande sera préalablement approuvée par le maître de stage ou encore par le responsable du département de radiologie de l’université ayant délivré au candidat son diplôme de docteur en médecine, chirurgie et accouchements.

b) Bourse de recherche : Le candidat déposera un projet de recherche approuvé par le titulaire de l’enseignement de radiologie de son université auprès du Bureau de la SRBR. Ce projet structuré comprendra la description de la recherche ainsi que les moyens nécessaires. 3. a) Bourse de voyage : Le choix se portera préférentiellement sur des projets d’études effectués lors d’un séjour d’environ deux mois dans un centre de radiologie étranger, dans le but d’acquérir ou de perfectionner une expérience particulière de l’une ou l’autre méthode d’investigation radiologique ou dans le but d’améliorer les connaissances du candidat dans l’un ou l’autre domaine de la radiologie. b) Bourse de recherche :

als project komt in aanmerking een welomschreven studie in één of ander domein van de radiologie waarvan mag verwacht worden dat ze een belangrijke bijdrage levert tot de radiologische wetenschap en dat ze zal leiden tot een publicatie in een reviewed tijdschrift.

Peut être pris en considération le projet s’inscrivant dans le domaine de la radiologie susceptible de représenter une contribution importante aux sciences radiologiques et qui est susceptible d’être publié dans une revue internationale à comité de lecture sélectif.

4. Zowel voor de reisbeurs als voor de researchbeurs dient het project voorgelegd te worden aan het bureau van de KBVR.

4. Les demandes de bourse de voyage et de bourse de recherche seront soumises au Bureau de la SRBR.

5. a. Reisbeurs:

5. a) Bourse de voyage :

binnen de 5 maanden na het beëindigen van de buitenlandse stage brengt de studiebeurslaureaat mondeling verslag uit bij het bureau van de KBVR over zijn studiereis. De reisbeurslaureaat verbindt er zich toe een wetenschappelijke bijdrage met betrekking tot zijn project te publiceren in het JBR-BTR.

Endéans les cinq mois suivant la fin de stage à l’étranger, le lauréat de la bourse d’étude présentera un compte-rendu oral de son voyage d’étude au Bureau de la SRBR. (continued on JBR-BTR 2011, 94-1: p. 56)

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Leuvensesteenweg 250 A 1800 Vilvoorde Tel. 02/711 46 80 Fax 02/725 20 87 Mr. E. Coppens

Sectra ImaXperts BV

Bracco Imaging Europe n.v./s.a. Belgian Branch Avenue Pasteurlaan 6 1300 Wavre Tel. 010/68 63 76 Fax 010/68 63 63 Mrs. N. Maes

Fuji Medical Systems Benelux Europark Noord 25 9100 Sint-Niklaas Tel. 03/760 03 33 Fax 03/766 699 Mr. G. Van Acker

Televisieweg 37A 1322 AJ Almere, The Netherlands Tel. +32 (0)3 226 31 81 Mobile +32 (0)476 37 00 67 E-mail: johan.leblicq@sectra.com Mr. Johan Leblicq

Editor: Professor J. PRINGOT, Koning Leopold III laan 20, B-3001 HEVERLEE Lid van de Unie van de Uitgevers van de Periodieke Pers Membre de l’Union des Editeurs de la Presse Périodique Printed in Belgium by UNIVERSA PRESS, Honderdweg 24 - B-9230 WETTEREN

For the best image quality half the dose is enough

we WELCOME Dr. Verbeek (Mechelen) AS NEW MICRODOSE MAMMOGRAPHY CLINIC Highest image quality. Half the radiation Sectra MicroDose Mammography™ is based on the patented photon-counting technology, which allows the creation of high-contrast images at the lowest r adiation dose. The system is designed for dependable diagnosis, superior ergonomy and enhanced comfort for women.

More info? Sectra Benelux, Pegasuslaan 5 - 1831 Diegem +32 2 709 29 34 - info.benelux@sectra.com www.sectra.com/medical/microdose

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