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ABSTRACT |
Freckleton M.W.; Dalrymple N.C.; Rahimi O.B.; Stein J.C.; Wong A.A.; Freckleton J.W.; Chhaya S.A.; Johnson L.Y.; Usatine R.P.; Dodd G.D.; Radiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX.
Address correspondence to M.W. Freckleton (freckleton{at}uthscsa.edu)
Background: Gross human anatomy largely continues to be taught as it was over 100 years ago. Recent advances in cross sectional imaging, 3-D reconstruction, information management, and interactive, multi-media display have given the health care professional new tools to understand and better utilize anatomical relationships. To date, we know of no program which fully integrates these technological advances in order to help the student understand not only the names of specific anatomical structures, but to visualize complex relationships between structures.
Key Issues: This module in urological anatomy highlights a new, innovative educational system—the Virtual Anatomy Project (VAP) -- integrating imaging, reconstruction, information management and multi-media into a comprehensive, interactive library of image and data objects. The goal of the VAP is to create a rich, visual library of easily accessible objects which can be intuitively manipulated. The VAP introduces a layered learning process, utilizing dissection guides, basic text, and then detailed text, linking key learning points within the layers of text with a library of graphical representations of these points. The student is able to review text, movies, images, and illustrations, and instructors are able to customize this data into advanced learning modules at will. The VAP can therefore be used as a comprehensive anatomy atlas, virtual dissection guide, interactive text book, or object library for construction of new modules, and by natural extension forms a repository for abnormal anatomy cases otherwise known as pathology.
Format: The core functionality of the VAP project is information management, largely accomplished through a robust database design with links to image, text, and multi-media objects. The graphical user interface of the VAP is Web-based, so that the system can be updated and enhanced continuously. Because of the database backbone, the format of the system is user-selectable, and the student can interface with it as an atlas, textbook, reference manual, teaching file, self test or review module, or even as an interactive game.
Teaching Points: 1- New concepts in medical instruction utilizing information management technologies 2- Creating a layered approach to medical instruction 3- Better understanding of urological anatomy and pathology through implementation of new learning tools.
E187. CT Urography: Evaluation of Strategies for Opacification of the Collecting System
Sanyal R.; Taori K.; Deshmukh A.; Department of Radiodiagnosis, Government Medical College, Nagpur, Maharashtra, Indonesia.
Address correspondence to R. Sanyal (rupansanyal{at}rediffmail.com)
Objective: To compare various protocols for the opacification of the collecting system in CT urography.
Materials and Methods: 60 patients underwent CT urography for various indications, during which 2.5mm collimation scanning was done 8 to 10 minutes after contrast administration. In the time interval between the initial contrast administration and scanning in the pyelographic phase, various techniques were applied to maximize the opacification of the collecting system. Patients were scanned after 10 mg iv furosemide injection (15 patients, 30 ureters); after 250 ml saline infusion in the supine position (15 patients, 30 ureters); after 250 ml saline infusion in prone position (15 patients, 30 ureters);and iv buscopan injection along with 250 ml saline infusion in the prone position (15 patients, 30 ureters). Buscopan was added due to its antiperistaltic effect on the ureters. During evaluation of the images, each collecting system and ureter was divided into six anatomic segments: upper and lower intrarenal collecting system, renal pelvis, and proximal (above iliac crest), lower (to the level of the sciatic notch), and distal ureter (below the sciatic notch). Each segment was assigned a score according to the opacification as follows: 0, unopacified; 1, less than 50% of segment opacified; 2, more than 50% of segment opacified; 3, entire segment opacified. Statistical analysis was done using paired Student t test to compare the opacification scores of the different acquisition techniques.
Results: The renal pelves and calyces were completely opacified in all four groups. Furosemide administration resulted in complete opacification of 93% ureters (28 of 30). In distal ureter, the mean score with furosemide was 2.9 while that with saline supine and prone positioning was 1.86 and 1.83, respectively, and this difference was highly significant (p = 0.0001). It was also significantly higher than the buscopan group (score 2.3, p = 0.0154). In mid and upper ureter also furosemide had significantly higher scores than saline infusion in either position. Saline infusion in supine and prone positions had very similar scores in all segments which were less than the buscopan group but this difference was not statistically significant.
Conclusion: During CT urography, furosemide administration in very low doses is highly effective in significantly improving the delineation of the ureters as compared to saline infusion in either prone or supine position, or addition of buscopan to saline supplementation.
E188. Patient Radiation Dose at Multidetector CT and Conventional Urography (IVU) for Acute Flank Pain. Patient Radiation Dose at Multidetector CT and Conventional Urography (IVU) for Acute Flank Pain
Eikefjord E.N.; Rørvik J.; Ulvik N.M.; Seyedzadeh M.; Department of Radiology, Haukeland University Hospital, Bergen, Norway.
Address correspondence to E.N. Eikefjord (eli.eikefjord{at}student.uib.no)
Objective: To measure and compare patient effective doses (ED) from multidetector computed tomography (MDCT) and intravenous urography (IVU) for acute flank pain.
Materials and Methods: 117 patients with acute flank pain were included. Everyoneunderwent both MDCT (GE) with 4 x 3, 75 mm collimation, 120 kVp, 200 mAs and pitch 1,5 and IVU with 70 kVp and an automatic mA device (Canon DR) as standard parameters. The CT protocol included one volumetric acquisition of the abdomen and pelvis at standard parameters, mA varying due to patient size. The IVU protocol consisted of a standard acquisition of 3 AP images, total number varying (mean 5 images). Effective doses were computer-simulated by using dosimetry programs for CT and conventional radiography, based on NRPB dose data sets from SR 250 and SR 262 respectively. Mean and SD of measured patient doses were calculated.
Results: The mean patient ED were 7, 7 mSv and 3,63 mSv for MDCT and IVU, respectively. Consequently MDCT gives an ED which is about double that for IVU at our standard protocols. There was estimated a difference in ED of nearly 22 % between men and women. The dose varied considerably more for IVU than for MDCT, as shown by the standard deviation (SD) of 2, 91 and 1, 86, respectively.
Conclusion: The ED of the standard MDCT protocol was over double the size of that of the IVU protocol. An optimized low-dose protocol should be considered before establishing MDCT for urethral colic to minimize radiation induced cancer risk and secure adequate image quality. A low-dose MDCT protocol will be evaluated in a coming study.
E189. Imaging Spectrum of Renal Pelvis Lesions
Kim Y.1; Cho H.1; Jung J.2; Han S.1; 1. Radiology, Inje University, Busan Paik Hospital, Busan, South Korea; 2. Urology, Inje University, Busan Paik Hospital, Busan, South Korea.
Address correspondence to Y. Kim (kyw47914{at}hanmail.net)
Background: The renal pelvis is a part of urinary system and central cavity surrounded by the kidney parenchyma adipose tissue, lymphatics, nerve fibers, fibrous tissue and vessels. Various pathologic conditions can occur from constituents around the renal pelvis and surrounding renal parenchyma.
Key Issues: Pathologic conditions of the renal pelvis are divided into several categories: 1)Inflammatory lesions including pyogenic abscess, granulomatous infection, xanthogranulomatous pyelonephritis, emphysematous pyelonephritis 2) cystic lesions including parapelvic cyst 3) neoplasm originating from the renal pelvis such as transitional cell carcinoma and extending from renal parenchymal tumor such as renal cell carcinoma, Wilms' tumor and the hematogenous metastasis 4) congenital lesions including ureteropelvic junction obstruction, renal pelvis duplications 5) calculi including staghorn stones and renal pelvic stones with duplications and horseshoe kidney 6) vascular lesions including renal artery aneurysm, arteriovenous malformation.
Format: This exhibit will present characteristic radiologic features of various renal pelvis lesions on ultrasound, CT and MRI.
Teaching Points: To describe the normal anatomy and constituents around the renal pelvis. To list a broad spectrum of lesions that involves the renal pelvis. To review and illustrate the spectrum of pathology of the renal pelvis.
E190. Granulomatous Renal Disease: An Interactive Teaching File
Birkholz J.H.; Hartman D.S.; Department of Radiology, Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA.
Address correspondence to J.H. Birkholz (james.birkholz{at}gmail.com)
Background: A myriad of granulomatous pathological processes involve the genitourinary system, resulting in varied imaging presentations. This exhibit provides the pathological foundation for an approach to interpreting these images.
Key Issues: The exhibit is an autotutorial. An overview of the basic pathology of urinary tract granulomatous disease is presented. The granulomatous diseases include tuberculosis, xanthogranulomatous pyelonephritis, malakoplakia, echinococcus, schistosomiasis.
Format: The overview is followed by 10 unknown cases. Imaging modalities include conventional radiography, urography, sonography, CT and MRI. Each unknown case is accompanied by a brief history, unlabeled images, annotated images with explanation of the findings, a list of the appropriate differential considerations, the diagnosis and a brief discussion of the entity.
Teaching Points: This exhibit will enable users to recognize and understand the imaging findings of granulomatous disease of the urinary tract, so that they may gain confidence in providing a reasonable differential diagnosis, thereby improving patient care.
E191. Automatic Versus Manual Segmentation of Porcine Kidney Imaged on 64-slice MDCT: In-vivo Volume Determination with Comparison to Ex-vivo Weight of the Kidney
Holalkere N.1; Sahani D.1; Cai W.2; Matthes K.3; Harris G.J.3; 1. Abdominal Imaging and Interventions, Massachusetts General Hospital, Boston, MA; 2. 3D Lab, Massachusetts General Hospital, Boston, MA; 3. Gastroenterology, Massachusetts General Hospital, Boston, MA.
Address correspondence to N. Holalkere (nholalkere{at}partners.org)
Objective: 1) To compare in-vivo automatic segmentation (AS) of porcine kidney imaged on 64-slice MDCT with manual segmentation (MS) and its impact on time saving. 2) To validate in-vivo AS by correlating with weight of the kidney ex-vivo.
Materials and Methods: An abdominal scan of 20 anesthetized Yorkshire breed pigs (weight range 45 to 50 kg) was performed on 64-slice MDCT (Sensation 64, Siemens) after an injection of iodinated (600 mgI/kg) contrast through an IV cannula. In-vivo AS was performed using a user built technique called propagating shell with dynamic thresholding. In-vivo MS was performed on a dedicated workstation by tracing the region of interest by a radiologist. The volume of kidneys was calculated using both the methods and the required time for calculation was noted. The pigs were sacrificed and weights of the dissected kidneys were measured. The in-vivo kidney volumes by two methods were correlated with each other and with ex-vivo weight of the kidney. Correlation co-efficient was determined for each comparison. Further, the dissected kidneys specimens were re-scanned and volumes were again calculated by both AS and MS and compared with the dissected kidney weight.
Results: A good correlation of ex-vivo volume of the specimen kidneys (140 gms) on AS (143 cc) and MS (144 cc) with the ex-vivo weight was noted. The estimated mean in-vivo volumes of 20 kidneys by AS and MS were 155.7 ± 32 cc 152.5 ± 26 cc respectively and a good correlation between the two methods (r = 0.89, p < 0.001) was observed. The measured mean ex-vivo weight of 20 kidneys was 133.5 ± 25 grams with a comparable volume on AS (r = 0.86, p < 0.001). There was a 12 to 20% variation in the weight of the ex-vivo kidney in comparison to in-vivo volume measurements by AS and MS. The average time for segmentation of a kidney by AS was 1.3 min (1.1 to 1.6 min) as compared to 5.3 min (4 to 7 min) by MS.
Conclusion: Automated segmentation technique allows rapid estimation of porcine kidney volume imaged on 64-slice MDCT with good correlation to manual segmentation method and ex-vivo weight measurement.
E192. Comparison of Volume Acquisition Mode (Cine Loop) Versus Standard 2D Gray Scale Imaging of Kidneys - Preliminary Results.
Jandzinski D.1; Van Wijngaarden E.2; Conde A.1; Dogra V.1; Rubens D.1; 1. Diagnostic Radiology, Strong Memorial Hospital @ University of Rochester, Rochester, NY; 2. Community and Preventative Medicine, University of Rochester, Rochester, NY.
Address correspondence to D. Jandzinski (Dana_Jandzinski{at}urmc.rochester.edu)
Objective: We evaluated several aspects of obtaining 3D versus standard 2D images of kidneys. The objectives of this study were to 1) Compare the visualization of parenchymal anatomy in 2D and volume acquisition mode (VAM). 2) Compare mean number of renal lesions detected on each set of images; 3) Compare intrarater kappa agreement.
Materials and Methods: This study was approved by the University of Rochester's Institutional Review Board. After obtaining informed consent, 40 patients referred for renal diagnostic ultrasound evaluation were prospectively enrolled in the study between May and September 2005. Imaging was performed in 2D by one sonographer and the VAM examination performed by a second sonographer, without knowledge of the 2D results. The VAM protocol included single frame images plus VAM images. Images were obtained with 2.5 to 5 MHz transducers utilizing a GE Logic 900 machine. Images were stored and read blindly and separately in a randomized fashion by a single radiologist. Images were scored for the proportion of the kidney visualized, with 80–100% being the highest score possible. The number of renal lesions or cysts was recorded in each set of images.
Results: Over 75% of kidneys had optimum visualization (80–100% category) with VAM vs. only 30% with 2D. The number of patients with focal abnormalities (stones, cysts, renal lesions) was 21. Five patients had better lesion detection on 2D renal stones (2) and small cysts (4). Twelve patients had more lesions on VAM; multiple increased cysts (10) and stones (2). The agreement rate for calculi detection in both kidneys is 0.46. The agreement rate for cyst detection in both kidneys is 0.66.
Conclusion: There is markedly improved visualization of renal parenchyma and cyst detection in VAM mode. The agreement rate for detection of cysts is significant.
E193. Sequential Changes after Radiofrequency Ablation and Cryoablation of Renal Neoplasm: Interpretation of CT and MRI
Kawamoto S.1; Permpongkosol S.2; Bluemke D.A.1; Fishman E.K.1; Solomon S.B.1; 1. Radiology, Johns Hopkins Hospital, Baltimore, MD; 2. Urology, Johns Hopkins Hospital, Baltimore, MD.
Address correspondence to S. Kawamoto (skawamo1{at}jhmi.edu)
Background: Radiofrequency ablation and cryoablation are increasingly used as minimally invasive treatments for renal malignancies. Accurate assessment of lesions on imaging studies after these procedures is essential to evaluate the adequacy of treatment and guide further management.
Key Issues: Usually, immediately after ablation, the lesions appear larger than the original mass, and on follow-up exam, are seen as focal masses without contrast enhancement which frequently decrease in size. Linear circumferential density in the perirenal fat is commonly seen after RF ablation. Intravenous contrast is essential to evaluate possible residual or recurrent tumor. This presentation will discuss and illustrate the spectrum of appearance of post ablation changes of renal tumors. Evolution of CT and MRI appearance of successful RF and cryoablation changes, and examples of tumor recurrence are discussed and illustrated. Signs of tumor recurrence include development of nodular enhancement and increase in lesion size.
Format: Didactic Organizational structure: by ablation and imaging technique.
Teaching Points: 1. To discuss and illustrate the spectrum of appearance of post ablation changes of renal tumors, and evolution of CT and MRI appearance of successful RF ablation and cryoablation. 2. To discuss and illustrate signs of tumor recurrence after RF ablation and cryoablation.
E194. The Clinical Utility of Histogram Analysis in CT Imaging of Adrenal Lesions
Slattery J.M.1; Blake M.A.; Boland G.W.1; Sweeney A.T.2; Mueller P.R.1; 1. Radiology, Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, MA; 2. Medicine/Endocrinology, St. Elizabeth's Medical Center, Boston, MA.
Address correspondence to J.M. Slattery (jslattery4{at}partners.org)
Objective: To determine the clinical utility of histogram analysis of adrenal lesions on CT.
Materials and Methods: A retrospective analysis of adrenal protocol CT imaging (non contrast, contrast enhanced and 10 min. delayed post contrast) from 2001 to 2005 using histogram analysis of adrenal lesions in each phase of contrast was performed. The region of interest used to generate the histogram covered 100, 400, or 900 pixels depending on the size of the lesion. Lesions had been previously classified as benign (adenoma) by CT criteria or malignant (metastasis) by CT/biopsy or interval growth on imaging. Adrenal lesions on which histogram analysis yielded negative pixel values were deemed to contain lipid. These values were correlated to the lesion's classification as malignant or benign.
Results: 52 lesions (L/R = 24/28) in 52 patients (M/F = 30/22, age range 32–79, mean age 61) were analyzed. 20 lesions were benign by non-contrast CT criteria (< 10 HU). 32 lesions were indeterminate by non-contrast CT criteria (> 10 HU) 19 and 13 of which classified as adenomas and metastases on washout analysis respectively. On the contrast enhanced CT 13/20 (65%) of the adenomas with non-contrast attenuation < 10 HU, 6/19 (30%) of the adenomas with non-contrast attenuation > 10 HU and 0/13 metastases (0%) demonstrated negative pixel values on histogram analysis.
Conclusion: All the lesion in our study which exhibited negative pixel values in the contrast enhanced phase CT were adenomas while none of the metastases demonstrated negative pixel values. Histogram analysis of adrenal lesions useful to detect lipid rich adenomas on contrast enhanced CT and may obviate the need to proceed to three phase adrenal protocol CT or MRI for further characterization.
E195. Retroperitoneal Fibrosis Revisited: Review of Current Diagnostic Methods, Radiologic Presentations, Treatment, and Follow-up
Levin G.1; Katz D.S.1; Choi A.Y.1; Hines J.2; Friedman B.2; Coll D.3; Fruauff A.A.1; 1. Radiology Department, Winthrop-University Hospital, Mineola, NY; 2. Radiology Department, Long Island Jewish Medical Center, New Hyde Park, NY; 3. Radiology Department, Mount Sinai Hospital, New York, NY.
Address correspondence to G. Levin (glevin{at}winthrop.org)
Background: Retroperitoneal fibrosis is a rare condition which is challenging both for establishing the correct diagnosis based on imaging findings, and for determining the appropriate clinical management. RP fibrosis may be idiopathic or may be due to an underlying process such as an aneurysm. The radiologist's role is crucial in early recognition of this disease, since clinical symptoms are usually non-specific and may initially be absent. Additionally, the imaging findings may vary depending on the chronicity of the fibrosis. Timely intervention and treatment can help to avoid detrimental consequences of this infiltrating and progressive disease.
Key Issues: The purpose of this educational exhibit is to review the clinical, radiologic, and pathologic features of retroperitoneal fibrosis as well as current treatment options. A variety of examples will be shown on IVU, CT, and MR, including complications. The differential diagnosis will also be illustrated, including lymphoma and retroperitoneal sarcoma.
Format: Case presentation, intermixed with literature review.
Teaching Points: To review the imaging findings of retroperitoneal fibrosis, using IVU, CT, and MR images. To understand the natural history and treatment options for retroperitoneal fibrosis. To review the differential diagnosis for retroperitoneal fibrosis on imaging studies.
E196. Imaging of Uncommon Retroperitoneal Pathology
Rastogi S.1; Chantra P.2; Chin E.; Zimmerman P.2; Lu D.1; Raman S.1; Cochran S.1; Kadell B.1; 1. Radiological Sciences, University of California at Los Angeles, Los Angeles, CA; 2. Department of Radiology, Greater Los Angeles VA Healthcare System, Los Angeles, CA.
Address correspondence to S. Rastogi (srastogi{at}mednet.ucla.edu)
Background: The retroperitoneum is a common site of pathology from a variety of entities such as lymphadenopathy and hematoma. However, there are numerous uncommon entities which are important to recognize. While many have non-specific findings, some have pathognomonic features on cross-sectional imaging using ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). We present the imaging features of a wide array of rare retroperitoneal diagnoses with pathologic correlation.
Key Issues: A variety of uncommon diseases involving the retroperitoneum using US, CT, and MRI will be exhibited with pathologic correlation. These include but are not limited to: xanthogranulomatous pyelonephritis with extra-renal extension, angiosarcoma, dedifferentiated liposarcoma, retroperitoneal fibrosis, Erdheim-Chester disease, pneumoretro-peritoneum from duodenal rupture, aortic ulceration, and mycotic aortic aneurysm.
Format: The presentation will be in a didactic format discussing the clinical, imaging, and pathologic features of the various diagnoses followed by a self-assessment quiz.
Teaching Points: Familiarize the audience with the cross-sectional imaging manifestations and diagnostic features of a variety of uncommon retroperitoneal pathology.
E197. Imaging Complications of Renal Transplantation in Children
Rajiah P.; Shabani A.; Radiology, Royal Manchester Children's Hospital, Manchester, United Kingdom.
Address correspondence to P. Rajiah (rprabhakar73{at}yahoo.com)
Background: The management of end stage renal disease in children has been revolutionized with the advent of renal transplantation, which offers good quality of life with low morbidity. The survival rates are very good due to excellent immunosuppressants. Imaging plays an important role in diagnosis and management of the complications arising in the renal transplant. It is essential for the practicing radiologist to know the normal appearances and diagnose earlier complications
Key Issues: Ultrasound, Doppler and nuclear medicine are the main imaging modalities used in renal transplant recipients. CT scan, MRI and angiography are used in indeterminate cases. The various pathologies demonstrated in our pictorial review include rejection. Acute tubular necrosis, Cyclosporine toxicity, infection, lymphocele, urinoma, haematoma, abscess, renal arterial stenosis, renal vein thrombosis, AV fistula and obstruction. Opportunistic infections and post transplant lympho proliferative disorder are the complications of immunosuppression.
Format: The exhibit starts by reviewing the normal sonographic appearances of a pediatric renal transplant. This is followed by a pictorial review of different pathological processes in the renal transplant and complications of immunosuppression. The role of different imaging techniques are discussed.
Teaching Points: 1. To illustrate the role and limitations of imaging in pediatric renal transplant recipients 2. To understand the normal ultrasound and Doppler appearances of renal transplant 3. To learn the imaging spectrum of pathological conditions affecting the renal transplant & complications of immunosuppression 4. To demonstrate the role of interventional radiology in management of complications.
E198. Magnetic Resonance Voiding Cystourethrography for Vesicoureteral Reflux
Takazakura R.1; Johnin K.2; Furukawa A.1; Nitta N.1; Takahashi M.1; Murata K.1; 1. Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan; 2. Urology, Shiga University of Medical Science, Otsu, Shiga, Japan.
Address correspondence to R. Takazakura (rtryu{at}belle.shiga-med.ac.jp)
Objective: To assess the feasibility of magnetic resonance voiding cystourethrography using non-enhanced MR fluoroscopy for evaluation of vesicoureteral reflux and the possibility of it being a noninvasive alternative to the gold standard voiding cystourethrography (VCUG).
Materials and Methods: A total of 22 MR studies of 16 patients with primary vesicoureteral reflux diagnosed by standard voiding cystourethrography were evaluated. Six patients underwent MR studies and standard voiding cystourethrography preoperatively and postoperatively. MR fluoroscopy was executed with the non-enhanced heavily T2-weighted single shot fast spin echo sequence with thick-slab acquisitions (fat-suppressed single-shot fast spin-echo; 1,800/800, 90° flip angle, 50-mm slab thickness in coronal, 256 x 224 matrix). The diagnosis of vesicoureteral reflux by MR study was positive when the dilatation of the ureter or renal pelvis during micturition was observed. The MR findings were correlated with those obtained by the gold standard, standard voiding cystourethrography.
Results: Of the 44 kidney-ureter units, 20 were refluxing on magnetic resonance voiding cystourethrography and 21 on standard voiding cystourethrography. There were one false-positive and two false-negative units. Magnetic resonance voiding cystourethrography was showed to be 90% sensitive with a specificity of 96% for detecting vesicoureteral reflux. Two false negative units were found in mild cases, grade I and II. For the units of grade III, IV and V(high grade reflux), magnetic resonance voiding cystourethrography detected all of the refluxing renal collecting systems.
Conclusion: Magnetic resonance voiding cystourethrography demonstrates high grade reflux without ionizing radiation or catheterization.
E199. The Radiologist's Role in Diagnosis and Management of Ruptured Ectopic Pregnancies
Green P.M.; Ernst R.; Oto A.Y.; Cesani F.; Snyder R.; Ethridge K.M.; Radiology, University of Texas Medical Branch, Galveston, TX.
Address correspondence to P.M. Green (pmgreen{at}utmb.edu)
Background: Clinical presentation of a patient with ruptured ectopic pregnancy may be nonspecific and includes a combination of orthopnea, pain, vaginal bleeding, and a palpable tender adnexal mass. Results of other diagnostic tests, such as quantitative serum hCG titer, serum progesterone, and complete blood count are helpful; however, test results may be misleading and a CBC may be normal if obtained prior to rupture. To eliminate uncertainty, prompt ultrasound may assure the ER physician of the diagnosis of ruptured ectopic while surgery is arranged.
Key Issues: We demonstrate examples of ruptured ectopic pregnancies including a delayed rupture following medical treatment and a cornual or interstitial pregnancy. We describe long-term follow-up care indicated for patients medically treated for ectopic pregnancies.
Format: This didactic exhibit uses static GIF and moving GIF images in PowerPoint format to demonstrate ruptured ectopic pregnancies.
Teaching Points: 1. Present ultrasound, CT, and MR findings useful in the diagnoses of ruptured ectopic pregnancies. 2. Describe indications, contraindications, and complications of medical management of ectopic pregnancies. 3. Demonstrate pathologies, such as hemorrhagic ovarian cysts, that mimic ruptured ectopic pregnancies.
E200. Cytogenetics and Molecular Biology of Ovarian Cancers: Implications on Diagnosis and Treatment
Prasad S.R.1; Narra V.R.2; Huettner P.C.3; Dalrymple N.C.1; Chintapalli K.N.1; 1. Radiology, University of Texas Health Science Center @ San Antonio, San Antonio, TX; 2. Radiology, Mallinckrodt Institute of Radiology, San Antonio, TX; 3. Pathology, Washington University in St. Louis, St. Louis, MO.
Address correspondence to S.R. Prasad (prasads{at}uthscsa.edu)
Background: Ovarian carcinoma is the fourth most common cause of cancer death in women in the US. It is the most lethal of all gynecological cancers. Ovarian carcinoma is a heterogeneous disease with different histopathologic subtypes and variable biologic profiles. Recent advances in pathology and molecular biology have provided unique insights into the histo-pathogenesis and biology of ovarian neoplasms.
Key Issues: Ovarian carcinoma is postulated to be a byproduct of genetic events that may involve promotion of proto-oncogenes, suppression of cancer suppressor genes or a combination of both mechanisms. Molecular imaging techniques such as optical imaging and spectroscopy have been employed to permit early diagnosis of cancer as well as to monitor treatment response to novel chemotherapeutic agents. Molecular therapeutic agents aimed at specific molecular targets are being increasingly developed and used to treat patients with ovarian cancers. A clear understanding of the pathogenesis and tumor biology provides rational explanation for the wide spectrum of histological subtypes of ovarian cancer, clinico-biologic behavior, and radiologic-pathologic manifestations.
Format: Didactic with histopathology, molecular imaging and cross-sectional imaging techniques.
Teaching Points: 1. To review the molecular genetics and biology of the ovarian cancers. 2. To discuss multi-step, polychromosomal carcinogenesis of ovarian cancers. 3. To discuss diagnostic and therapeutic implications of various histological subtypes of ovarian cancers.
E201. Evaluation of An Adnexal Mass: A Pattern-recognition Approach
Patel M.D.; Radiology, Mayo Clinic, Scottsdale, AZ.
Address correspondence to M.D. Patel (patel.maitray{at}mayo.edu)
Background: Evaluation of an adnexal mass, either presenting on physical examination, suspected based on clinical history, or identified on routine pelvic sonography, is a common task for the sonologist. While the clinical context is very important, for the vast majority of sonographically-identified adnexal masses, the subsequent management of the patient will be highly dependent upon the sonologist's interpretation of the imaging findings. The sonologist who merely measures the size of a mass and who subsequently offers a differential diagnosis that includes nearly every adnexal abnormality, including malignancy, has failed in his or her opportunity to contribute meaningfully to the care of the patient. Using a practical approach and with knowledge of the sonographic patterns of adnexal pathology, the sonologist is better equipped to make reasoned conclusions and useful recommendations for patient management.
Key Issues: This educational exhibit describes a diagnostic algorithm for analyzing a sonographically-identified adnexal mass, illustrates the sonographic patterns of adnexal pathology, reviews literature regarding the level of confidence sonologists can place on various observations for predicting certain pathologic conditions, and discusses practical considerations regarding additional testing in further evaluation of adnexal pathology.
Format: Didactic format with some interactive elements in the form of questions.
Teaching Points: Viewer will learn the sonographic patterns of the following entities with understanding of the likelihood ratios of various individual and combined observations: 1. corpus luteum 2. non-neoplastic cyst 3. hemorraghic ovarian cyst 4. endometrioma 5. paraovarian cyst 6. hydrosalpinx 7. peritoneal inclusion cyst 8. cystadenoma 9. cystic teratoma 10. cystadenocarcinoma.
E202. Gynecologic and Hormonal Effects of Raloxifene in Premenopausal Subjects at High Risk for Developing Breast Cancer
Premkumar A.1; Venzon D.2; Avila N.1; Johnson D.1; Remaley A.1; Eng-Wong J.2; Zujewski J.2; Stratton P.3; 1. Mark O Hatfield Clinical Center, National Institutes of Health, Bethesda, MD; 2. National Cancer Institute, National Institutes of Health, Bethesda, MD; 3. National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD.
Address correspondence to A. Premkumar (apremkumar{at}nih.gov)
Objective: Raloxifene, like tamoxifen is a potential chemopreventive agent in women at high risk for developing breast cancer. Since raloxifene may differ from tamoxifen in agonist and antagonist estrogenic effects on reproductive tissues, and since little is known about the effects of raloxifene in premenopausal women, we assessed the immediate and long-term effects of raloxifene on the ovaries, uterus, and serum hormone levels in high risk premenopausal women.
Materials and Methods: 30 women at high risk of breast cancer with regular menstrual cycles received 60 mg raloxifene daily for 2 years. Ovarian stimulation(seen as multiple corpus lutea and ovarian cysts), endometrial thickness, polyp development and fibroid size were assessed by transvaginal sonograms with color Doppler and sonohysterograms prior to receiving raloxifene, and at 1, 3, 12 and 24 months of raloxifene therapy. 14 had both follicular and luteal phase ultrasounds as well as a periovulatory scan in cycle 3. Serum hormone levels for estradiol, progesterone, LH and FSH were measured on 10 different days during the pre-treatment menstrual cycle, and the 3rd and 12th months post raloxifene. The other 16 had ultrasounds and serum hormones measured only once in the early follicular phase.
Results: 15/30 patients showed evidence of ovarian stimulation compared to 2 before treatment. New endometrial polyps were seen in 9/30 patients. All polyps were benign. Estradiol levels increased significantly in both follicular and luteal phases (178 pg/ml: p = 0.052 and 236 pg/ml: p = 0.027, respectively). Peak estradiol levels available for correlation with ultrasound (n = 8) were 40–100 % higher in stimulated cycles. Although 16 patients reported menstrual cycle length irregularities while on treatment, pretreatment median menstrual cycle length did not differ from that on treatment (26.3 versus 26.7 days, respectively) (p = 0.52). Uterine fibroids were seen in 16/30 subjects at baseline. 10/16 had an increase of fibroid size of > 1 cm/yr (range 1.1–2 cm, mean 1.2 cm).
Conclusion: Premenopausal patients on raloxifene had sonographic and hormonal evidence of ovarian stimulation. While there was no change in endometrial thickness or median menstrual cycle length, benign asymptomatic endometrial polyps developed in a significant number of patients. A slight increase in fibroid size was seen in some patients. These findings suggest that raloxifene may have a stimulatory effect on the ovaries and endometrium in premenopausal women, similar to other SERMS.
E203. Pelvic Anatomy and Pathology: Spaces of the Pelvis
Lamke G.T.; Oliphant M.; Radiology, Wake Forest University Baptist Medical Center, Winston-Salem, NC.
Address correspondence to G.T. Lamke (glamke{at}wfubmc.edu)
Background: The pelvis has complex topography due to several intra- and extraperitoneal spaces. Normal anatomy dictates the flow of fluid, infection, and cancer through the labyrinth of intraperitoneal pelvic spaces.
Key Issues: Extraperitoneal spaces are restricted by anatomic boundaries that also alter the progression and extent of involvement of disease in the pelvis and determine which organs are affected by direct invasion and compartmental spread of disease.
Format: The format for this presentation is didactic and interactive with test cases at the end of the presentation to solidify the physician's knowledge of the subject matter. Computed tomography is the central approach accompanied by illustrations and select other radiological studies.
Teaching Points: The central focus is on the relationships of pelvic structures in health and disease, and the patterns of disease spread through these contiguous and noncontiguous spaces. The presentation will aid the practicing radiologist in developing a search pattern when pathological features are found.
E204. Dynamic MR Imaging of the Pelvic Floor: Review of Anatomy, Techniques and Spectrum of Pathologies
Moulton S.J.; Bridges M.D.; Radiology, Mayo Clinic Jacksonville, Jacksonville, FL.
Address correspondence to S.J. Moulton (moulton.stacy{at}mayo.edu)
Background: Pelvic floor dysfunction is a vexing, and often progressive, problem that diminishes quality of life for many, particularly parous and aging women. As a greater variety of more effective medical and surgical strategies at last develop, more precise pretreatment diagnosis of the particular complex of defects affecting each individual becomes increasingly important. In the past, physical examination and fluoroscopic defecography have been the diagnostic mainstays. But physical examination often fails to appreciate the specific defect underlying a nonspecific symptom. And traditional defecography is technically complex, involving introduction of contrast into multiple systems; it also fails to visualize extraluminal lesions. In recent years, MR has become our institutional mainstay for evaluating patients with potentially complex multi-compartment involvement and for those who have had prior surgical repair or for whom a complex repair is planned.
Key Issues: MR is capable of excellent and manipulable soft tissue contrast. With the recent advent of fast, single shot sequences, it has also become capable of capturing dynamic processes. Consequently, small structures such as the urethra or specific supporting fascial condensations can be imaged in detail, as can their complex interactions during motion. Enteroceles, rectoceles and cystoceles are depicted clearly, as are prolapses, fistulas, and alternative diagnoses. In addition to axial and sagittal high-resolution TSE T2-weighted sequences, our pelvic floor protocol includes midline sagittal and coronal dynamic TrueFISP acquisitions as the patient performs a series of rest, Kegel, and straining maneuvers.
Format: Using multiple illustrative examples in a didactic and interactive approach, this exhibit will detail the protocol and setup of the MR exam, identify the normal anatomical structures and landmarks, and provide multiple examples of pelvic floor dysfunction.
Teaching Points: Teaching point: 1) Dynamic MR imaging of the pelvic floor provides detailed anatomic and physiologic information about pelvic floor function. 2) Knowledge of normal pelvic floor anatomy and mechanics is essential. 3) Multi-compartment dysfunction is clearly displayed with MR imaging and may have a major impact on subsequent treatment and surgical intervention.
E205. Dynamic MRI of the Female Pelvis: An Electronic Atlas of Pelvic Floor Dysfunction
Palmer S.L.; Sapra A.; Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
Address correspondence to S.L. Palmer (spalmer{at}usc.edu)
Background: Pelvic floor dysfunction (PFD) is a nonspecific condition encompassing urinary and fecal incontinence, pelvic organ prolapse, obstructed defecation, chronic pelvic pain and sexual dysfunction. This entity is not well understood, but accounts for a significant number of physician visits and hospitalizations annually. PFD manifests as abnormal pelvic floor descent associated with abnormal, symptomatic displacement of pelvic organs from their normal anatomic position. PFD can result in significant morbidity in the aging; 1 in 9 women will have surgery for this condition. Although the diagnosis is made on physical exam, imaging is important for workup and surgical planning. The imaging modality of choice is MRI due to its superior tissue differentiation and dynamic imaging capabilities. MRI can demonstrate occult defects of pelvic floor musculature and endopelvic fascia that cannot be detected on physical exam or other imaging modalities.
Key Issues: This educational exhibit reviews MRI techniques for the evaluation of PFD. Dynamic imaging is demonstrated and includes imaging during gluteal contraction, valsalva and evacuation maneuvers. Normal anatomy is presented, including review of the compartments of the pelvis, musculoskeletal support and fascial attachments. Some of the pathologic conditions featured include: cystocele, enterocele and rectocele; prolapse of the bladder, vagina and rectum; hyper mobility of the urethra; and discontinuity of levator musculature with and without visceral herniation.
Format: This is a didactic presentation that will provide the viewer with the opportunity to review normal pelvic anatomy and pathology related to PFD. This presentation will include a complete discussion of the techniques used in pelvic MRI including protocols for dynamic imaging, patient preparation and positioning and use of endoluminal contrast. A discussion of pitfalls and artifacts will be included.
Teaching Points: After reviewing this exhibit the viewer will: 1. Understand the anatomy of the pelvis, including the compartments, facial planes and supporting musculature. 2. Recognize pathological entities that arise from defects in the pelvic fascia and supporting musculature. 3. Understand how dynamic MRI is used for evaluation of PFD and be able to develop protocols for use in daily clinical practice.
E206. MRI Developments in Pelvic Floor Imaging
Kielar A.1; Weadock W.J.1; Hsu Y.2; DeLancey J.O.2; Hussain H.K.1; 1. Radiology, University of Michigan, Ann Arbor, MI; 2. Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
Address correspondence to A. Kielar (aniakielar{at}gmail.com)
Background: The new term "pelvic floor dysfunction" refers to the birth-related triad of pelvic organ prolapse, urinary incontinence and fecal incontinence. It is so common and distressing that 400,000 women require surgery each year. Recently, new imaging research has brought important insights into the pathophysiology and clinical management of these previously poorly understood conditions. MR imaging has defined specific anatomic abnormalities that can be seen such as newly discovered levator ani defects as well as pathologic findings such as cystoceles, uterine prolapse, enteroceles and rectoceles that are leading to new disease classifications. Additionally, MRI has provided insight into the anatomic abnormalities seen in patients with incontinence.
Key Issues: Using specific pelvic MRI sequences, high resolution static images can depict the muscular anatomy of each element of pelvic floor levator ani muscles. MRI cine images obtained both at rest and during Valsalva and Kegel maneuvers show the function of the pelvic floor muscles. This exhibit will review the current knowledge of female incontinence, and show the spectrum of imaging findings on MRI seen in this subgroup of patients. An optimal MRI imaging protocol will also be presented.
Format: This presentation will include a combination of didactic and interactive elements to provide an overview of normal female pelvic floor anatomy and compare it to abnormal cases. Examples demonstrating pathology such as cystoceles, rectoceles and enteroceles will be included for the interactive portion of the exhibit. A description of MRI sequences used to assess the pelvic floor anatomy will be provided. Future trends in this expanding field will also be discussed.
Teaching Points: Teaching points include a review of anatomy important for continence and changes related to incontinence. This exhibit will review the current state-of-the-art knowledge of "pelvic floor dysfunction", and show the spectrum of imaging findings on MRI seen in this subgroup of patients. An optimal MRI protocol will be presented, which could be implemented in other institutions for imaging the function of pelvic floor muscles.
E207. Optimizing Multidetector CT Technique for Abdominal-pelvic Examinations of the Pregnant Patient
Lee S.B.; Dalrymple N.C.; Prasad S.R.; Chintapalli K.N.; Radiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX.
Address correspondence to N.C. Dalrymple (dalrymplen{at}uthscsa.edu)
Background: The American College of Obstetricians and Gynecologists (ACOG) advises that CT and other imaging examinations are appropriate in the pregnant patientif the study might yield information critical to medical management. The opinion paper issued by ACOG in 2004 does not, however, discuss issues particular to multidetector CT (MDCT). Variables affecting radiation dose to the patient using MDCT are more numerous and complex than with single detector CT. Since considerable tube output is made available on modern scanners to accommodate demanding applications, there is potential for fetal exposure that exceeds ALARA principles if the complex factors affecting radiation dose are not taken into account when planning scan protocols.
Key Issues: Automated current modulation programs intended to optimize use of radiation may actually increase tube output when the fetus in the section of acquisition to compensate for the increased size of the gravid abdomen. While changes in tube current alter dose in a linear fashion, altering tube potential has a greater impact. Detector configuration, section thickness, table speed, and rate of gantry rotation must be considered. Out of concern for fetal exposure, CT examinations of pregnant women are usually performed after relatively thorough clinical evaluation and often have a directed diagnostic question (trauma, appendicitis, ureterolithiasis). The directed nature of these examinations may justify tolerating increased image noise compared to other abdominal-pelvic survey examinations in adult patients who are not pregnant.
Format: Didactic electronic exhibit discussing issues and controversies regarding the use of MDCT in pregnant patients. Organized according to imaging parameters.
Teaching Points: 1. Consider de-activating the automated current modulation to avoid increased tube output in the region of the fetus. Users with a thorough understanding of a particular modulation program may be able to use current modulation effectively by adjusting pre-set noise index or current limits. 2. "Acceptable" image quality with noise levels that are somewhat higher than usual may be preferred to "high" quality images in the goal-oriented evaluation of pregnant patients. 3. Use of larger section thickness (e.g., 7.5 mm rather than 5 mm) may yield diagnostically acceptable image quality with lower radiation dose.
E208. US and CT Appearance of the Essure Microinsert Permanent Birth Control Device
Wittmer M.H.1; Brown D.L.1; Hartman R.P.1; Famuyide A.O.2; Kawashima A.1; King B.F.1; 1. Department of Radiology, Mayo Clinic, Rochester, MN; 2. Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
Address correspondence to M.H. Wittmer (wittmer.michael{at}mayo.edu)
Objective: The Essure microinsert is a recently FDA-approved, hysteroscopic method of fallopian tube occlusion for permanent birth control. Radiologists are increasingly likely to incidentally encounter the device on pelvic US and CT. The purpose of this study is to describe the appearance and proper location of the Essure microinsert on ultrasonography (US) and computed tomography (CT).
Materials and Methods: After IRB approval, we searched the electronic medical records of all women who had undergone placement of the Essure microinsert at our institution between March 2003 and August 2004, and who subsequently had a pelvic US and/or CT scan performed. To record the imaging appearance and location of the device, the US and CT scans were reviewed and compared to the post-placement HSG, which is routinely performed 3 months after device placement per FDA requirement.
Results: Eight patients who had an Essure device placed were found to have had a CT and/or US of the pelvis performed after placement. Of these 8 patients, CT scans had been performed in 6 patients and US in 5 patients. By US, the proximal portion of the device was seen in all cases as a curving structure of parallel echogenic lines in the cornual region of the uterus. By CT, the entire device was seen in all cases as a hyperattenuating structure in the cornual region of the uterus. In all cases, the position of the device seen on US and CT was in agreement with that seen on HSG.
Conclusion: The Essure permanent birth control device has a distinct appearance on CT and US examinations, and can be accurately identified with these modalities. Recognition of the normal appearance and location of the device will hopefully facilitate accurate interpretation when these devices are incidentally encountered during pelvic US or CT.
E209. The Assessment of Endometrial Pathology and Tubal Patency of Infertile Patients: A Comparison Between MR-HSG and X-ray HSG
Turan A.; Arslan H.; Etlik O.; Temizoz O.; Sakarya M.E.; Celiker F.B.1; Colcimen N.; 1. Radiology, Yuzuncu Yil University Faculty of Medicine, Van, Turkey.
Address correspondence to A. Turan (arzuturan488{at}hotmail.com)
Objective: We aimed to evaluate role of MR Hysterosalpingography (MR-HSG) compared with conventional hysterosalpingography (X-Ray HSG) in tubal or uterine patency and luminal pathology in infertile females.
Materials and Methods: Forty-four of 50 infertile women prospectively underwent MR-HSG and X-ray-HSG. After the cervix cleaning and placing the Foley catheter into endometrial cavity, 20 ml diluted Gadolinium solution was injected into the uterine cavity and MR-HSG was performed with T1-weighted three-dimensional gradient echo sequence (3D Flash). All images were transferred to workstation (Leonardo, Siemens Medical Solution) for 3-D application. Then, the X-Ray HSG examination which was accepted as a gold standard was performed in all patients with classical method. Results were compared with chi-square test. Patients comfort was also evaluated after the both examination.
Results: MR-HSG examination was well tolerated in all cases. Endometrial cavity of all patients was evaluated with MR-HSG. Tubal patency, hydrosalpinx, peritubal adhesions can also be evaluated with MR-HSG. The accuracy of MR-HSG compared with X-Ray HSG for the uterine cavity, right and left tubes were 100%, 86% and 97%, respectively. We did not detect significant differences in the diagnostic performance between two techniques (p > 0.05). Most of the patients stated that MR-HSG was more comfortable and less painful than X-Ray-HSG.
Conclusion: Uterine cavity and tubal patency can be evaluated similarly with MR-HSG compared with X-Ray-HSG. In order to enable a one-step imaging procedure for evaluation of all pelvic pathology including endometrial cavity and tubal patency, MR-HSG can be used as an initial and sole modality without examining with X-Ray-HSG in infertile females.
E210. Unique MR Imaging Characteristics of Female Pelvic Masses
Murray J.P.; Adusumilli S.; Hussain H.K.; Weadock W.J.; Radiology, University of Michigan, Ann Arbor, MI.
Address correspondence to J.P. Murray (johnmurr{at}umich.edu)
Background: The traditional management of pelvic masses in female patients has included clinical and laboratory evaluation combined with ultrasonography and a relatively low threshold for surgical evaluation. MR imaging is emerging as a clinically useful addition to this management scheme. MR imaging is uniquely powerful in evaluating the female pelvis because of its ability to characterize soft tissue and its inherent multiplanar capabilities. A correct diagnosis of pelvic masses can triage patients to either appropriate surgical management (laparoscopic versus staging laparotomy) or in some cases, this diagnosis can prevent unnecessary surgery. In this exhibit, we will illustrate examples of pelvic masses with characteristic imaging findings yielding a highly specific diagnosis.
Key Issues: Examples with characteristic imaging findings (listed in parentheses) will include: presacral epidermoid cyst (keratin debris), pedunculated uterine fibroid (bridging vessel sign), ovarian fibrous tumor (low T1 and T2 signal intensity), dermoid (macroscopic fat, lipid), endometriomas (signal intensity of blood and T2 shading), pelvic neurogenic tumor (demonstrating contiguity with sacral nerve roots), ovarian cancer (mural enhancing nodules and papillary projections), and massive ovarian edema (stromal edema).
Format: The format of this exhibit will be an interactive tutorial. Each case will be initially presented as an unknown, and then the viewer will be given the opportunity to have characteristic findings directly illustrated with arrows and informative text.
Teaching Points: Characteristic findings on MRI can be diagnostic of several different female pelvic masses. The ability to recognize these findings (as demonstrated in this exhibit) can help guide clinical and, if necessary, surgical management of these patients.
E211. Hydatid Cyst-Typical and Atypical Presentations-A Pictorial Review
Rajiah P.; Khan A.; Radiology, North Manchester General Hospital, Manchester, Lancashire, United Kingdom.
Address correspondence to P. Rajiah (rprabhakar73{at}yahoo.com)
Background: Hydatid cyst is the larval stage of the worm Echinococcus granulosus for which man acts as an intermediate host. The cyst is most common in liver (75%) and lung (15%), but it can occur in any part of the body (10%), where it can confused with other cystic lesions.
Key Issues: This exhibit reviews the life cycle and composition of hydatid cyst. It also describes the various classification systems, which are used to assess the activity of the hydatid cyst. Ultrasound, CT and MRI are the modalities used in the diagnosis. The review illustrates the appearance of hydatid cyst in locations as diverse as liver, lung, spleen, kidney, peritoneum, retroperitoneum, bones, soft tissue, mediastinum, spine neck and brain. The common differential diagnosis of cystic lesions in different organs are discussed.
Format: Pictorial review illustrating the life cycle and imaging appearances in ultrasound, CT and MRI.
Teaching Points: A. To review the life cycle and development of hydatid cyst B. To illustrate the imaging appearances of hydatid cyst in common and uncommon locations C. To describe the radiological in relation to the activity of the disease.
E212. A Pictorial Review of the Anatomy and Radiological Characteristics of Common and Uncommon Male Pelvic Masses
Gonzalez M.A.; Szklaruk J.; Silverman P.M.; Patnana M.; Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX.
Address correspondence to M.A. Gonzalez (MGONZALEZ{at}DI.MDACC.TMC.EDU)
Background: Computed Tomography and Magnetic Resonance Imaging are commonly used for the evaluation of the male pelvis. Familiarity with normal anatomy, tissue planes, and the anatomical relationship between various organ systems is essential for accurate diagnosis. In addition, knowledge of the CT and MR appearance of common and uncommon pelvic masses is also a key factor to reach the correct diagnosis.
Key Issues: The male pelvic masses may be located in the peritoneal or extra-peritoneal space and may originate from the genitourinary, gastrointestinal, neurological, musculoskeletal, vascular and lymphatic systems. Common masses and uncommon male pelvic masses may be encountered. For example, a mass in the prostate may represent a common primary tumor such adenocarcinoma or an uncommon tumor such as small cell sarcoma or cystosarcoma phylloides of the prostate. Knowledge of the imaging characteristics may allow distinction between these diagnoses. When encountered with large tumors correct localization is often difficult and knowledge of anatomical landmarks is essential.
Format: This interactive electronic exhibit will review the anatomical spaces of the pelvis, the normal and variant anatomy, and the anatomical relationship between various organs systems. The exhibit will present the MR and CT appearance of common and uncommon male pelvic masses categorized by organ system. The participant will select from a master menu a specific organ of interest (i.e., prostate) and will then be asked to select from a list of topics that includes anatomy, common and uncommon masses. Upon selection of a specific topic, description and examples of the imaging characteristics will be presented. For example, images of tumors of the prostate such as adenocarcinoma, small cell sarcoma, and cystosarcoma phylloides of the prostate will be presented. The imaging features of the pelvic masses will be compared and contrasted and a description of the relevant clinical information including staging and pathology will be discussed. Anatomical landmarks used for correct diagnosis and localization will be reviewed via a quiz mode presentation.
Teaching Points: To illustrate the anatomical spaces and appearance of normal anatomy of the male pelvis. To learn the CT and MRI appearance of common and uncommon male pelvic masses. To review the relevant clinical information and pathology of male pelvic masses.
E213. Intraprostatic and Periprostatic Cystic Lesions -MRI Findings, Differential Diagnosis and Clinical Significance
Curran S.D.; Mehdizade A.; Akin O.; Zhang J.; Rademaker J.; Radiology, Memorial Sloan-Kettering Cancer Center, New York, NY.
Address correspondence to S.D. Curran (currans{at}mskcc.org)
Background: With increased use of magnetic resonance imaging (MRI) of the prostate, cysts within and adjacent to the prostate are more frequently identified. The prevalence of prostatic cystic lesions has been reported to be as high as 7%. Prostate cystic lesions can be divided into intraprostatic, periprostatic and pseudo-cystic lesions. Some are clinically important such as those that cause infertility due to ejaculatory obstruction near the midline, or cysts indicating underlying malignancy. Clinical findings combined with MRI features can help guide management.
Key Issues: An understanding of the detailed anatomy in and around the prostate is essential for interpretation of prostate MRI. Knowledge of the embryology of the Wolffian and Müllerian duct systems is also helpful in understanding normal anatomy as well as prostatic cyst location and development. We used high spatial resolution MRI of the prostate with an endorectal coil on a 1.5 Tesla magnet to obtain images in three orthogonal planes. Large field of view (FOV) T1-weighted images of the pelvis were followed by small FOV T2-weighted images for detailed assessment of the prostate.
Format: The differential diagnosis and classification of prostatic and periprostatic cystic lesions as well as lesions that mimic prostatic cysts or pseudo-cysts are discussed. The MRI findings, differential diagnosis and clinical features of some of the common cysts and pseudocysts are depicted.
Teaching Points: 1. Detailed embryology of the male Wolffian and Müllerian duct systems. 2. Differential diagnosis of cystic lesions as well as pseudo-cysts in and around the prostate. 3. State of the art high spatial resolution prostate MRI imaging technique. 4. MRI findings of many of the commonly encountered prostatic cystic lesions and their clinical significance.
E214. 3-D Doppler Sonography of Anterior Prostate Cancers
Bard R.L.; Radiology, Biofoundation for Angiogenesis R&D, New York, NY.
Objective: Compare value of 3D power Doppler sonography (3-D PDS) with MRI in evaluation of anterior nonpalpable prostate cancers in patients with Gleason scores of 6 and higher.
Materials and Methods: 356 patients were scanned with a Kretz Voluson 730 expert ultrasound unit employing endorectal 5-9 and 6-10 MHZ probes. All patients were scanned within 1 week with a 1.5 T Siemens MRI unit using large field T1-weighted images and small field axial, sagittal, and coronal T2-weighted images. Of 199 cancer patients, 150 had Gleason 6, 25 had Gleason 7, 20 had Gleason 8 and 4 had Gleason 9. Anterior tumors were documented by B scan with 3-D multiplanar reconstruction and/or by hypervascular foci and confirmed with MRI.
Results: 42 anterior tumors were located: 22 isolated lesions and 20 lesions associated with posterior coexistent tumors. Gleason 6 had 10 avascular tumors, Gleason 7 had 10 avascular tumors and 11 vascular tumors, Gleason 8 had 9 vascular tumor, Gleason 9 had 2 vascular tumors. MRI confirmed all lesions.
Conclusion: 3-D power Doppler sonography appears as sensitive as MRI in detection of anterior prostatic cancers.
E215. Scrotal Masses: From the Cradle to the Grave
Abedi M.; Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada.
Address correspondence to M. Abedi (percat7{at}hotmail.com)
Background: Scrotal masses are a common presentation among all male age groups and are often associated with an extensive list of potential diagnoses. Ultrasonographic imaging can greatly facilitate diagnosis of a scrotal mass by identifying the location of the mass as well as mass shape, size, and consistency. There is considerable variability regarding mass type and the patients age; lymphomas, for instance, are rarely found in the pediatric population while they tend to be the most common cause of a scrotal mass among elderly males. Review of ultrasonographic imaging of common scrotal mass manifestations by age group therefore, facilitates identification of these masses.
Key Issues: Ultrasonographic images with multi-modal correlation of the both pediatric and adult scrotal masses will be reviewed in addition to a literature review on intratesticular and extratesticular masses.
Format: This poster presentation will highlight the major presentations of scrotal masses from pediatric to adult males by ultrasonographical imaging. Some images will have correlated CT or MR images. Images of age-specific benign and malignant manifestations will be reviewed in a chronological order. The following intratesticular non-malignant presentations will be reviewed: cysts, adrenal rests, cystic dysplasia, epidermoids, torsion, focal orchitis and hematomas. Imaging of intratesticular malignancies such as germ-cell tumors will also be reviewed including, seminomas, embryonal carcinomas, yolk sac carcinoma, mixed cell carcinoma, choriocarcinoma, and teratomas. Non-germ cell tumors including, Leydig cell tumors, Sertoli cell tumors, lymphomas, metastases, leukemia, and tubular ectasia will also be reviewed. The presentation will also highlight extratesticular masses among both the pediatric and adult population and will review images of cysts, fibromas, leiomyomas and hemangiomas.
Teaching Points: 1) Familiarity with the most commonly presently benign and malignant mass types in various age groups; and, 2) Appreciation of patient age (as well as mass location)as an important component in the differential diagnostic algorithm of a scrotal mass.
E216. Sonographic and CT Findings in Unusual Intra-Scrotal Pathology
Yu N.C.1; Chantra P.2; Chin E.2; 1. Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA; 2. Department of Radiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA.
Address correspondence to N.C. Yu (nyu{at}mednet.ucla.edu)
Background: Intrascrotal pathology commonly investigated using imaging, primarily sonography, include hydrocele, varicocele, epidydimitis/epidydimo-orchitis, traumatic injury, testicular torsion, and primary testicular tumors.
Key Issues: In this exhibit, we present an array of atypical manifestations of such entities as well as more unusual and rare scrotal disorders, including but not limited to congenital (polyorchidism, cryptorchidism), infectious (intrascrotal abscess, Fournier's gangrene), malignant (primary and metastatic tumors, lymphoma), benign neoplastic (testicular hemangioma, leiomyoma, adenomatoid tumor), vascular (testicular infarction), and miscellaneous (iatrogenic injury, foreign body) pathology. Cases are presented emphasizing sonographic, and where appropriate, CT findings. Clinical and pathological correlation are provided, along with a review of pathophysiology.
Format: Actual cases will be presented with relevant clinical history, imaging findings, and pathological correlation, followed by brief didactic review of pathophysiology and management.
Teaching Points: The audience is expected to: 1) Develop a broader differential diagnosis of intrascrotal pathology, 2) recognize imaging features of less common testicular and extra-testicular disorders, 3) understand potential value of CT in selected cases, and 4) master basic concepts in clinical management and patient follow-up.
E217. Sonography of the Penis in the Evaluation of Peyronie's Disease: Review of Techniques and Interpretation
Conroy G.; Freimanis M.; Levine L.; Hibbeln J.; Sclamberg J.; Chen M.; Diagnostic Radiology, Rush University Medical Center, Chicago, IL.
Address correspondence to G. Conroy (gretchenconroy{at}rcn.com)
Background: Peyronie's disease, a fibroproliferative lesion of the penis which has an increased incidence of vascular abnormalities and erectile dysfunction, affects 9% of adult males. Sonography provides detailed anatomic and pathologic information, as well as dynamic functional assessment of penile vasculature, which are important to assess before definitive therapy.
Key Issues: This exhibit shows the role of sonography in the evaluation of Peyronie's disease and erectile function in this context. Appropriate imaging and vasodilator injection techniques are reviewed. Probe choice, depth, gain, and color and duplex settings are discussed. The spectrum of sonographic findings in Peyronie's disease is also shown. This includes plaques, calcifications, and thickening of the tunica albuginea. In addition, the use of vasodilator injection and the evaluation arterial and venous abnormalities is addressed. Measurement of penile bending and circumferences is shown.
Format: This is a didactic exhibit with static images, sonographic video clips, text, diagrams, clinical and intraoperative photos. Illustrations of penile anatomy, as well as intracavernosal injection technique are provided.
Teaching Points: 1. Provide an understanding of penile anatomy and the alterations experienced in Peyronie's disease. 2. Review optimal technique parameters including patient positioning, probe choice, ultrasound settings, the use of Color Doppler and vasodilator injection technique. 3. Provide an understanding of the importance of these measurements for planning medical therapy or surgical approach.
E218. Fournier's Gangrene: The Imaging Spectrum
Panu N.; Kriegler S.; Stoneham G.W.; Department of Medical Imaging, University of Saskatchewan, Saskatoon, SK, Canada.
Address correspondence to N. Panu (neety.panu{at}gmail.com)
Background: Necrotizing fasciitis (NF) is a rare but serious infection of the superficial fascia of subcutaneous fat and skin. Although necrotizing fasciitis can occur in any part of the body, necrotizing fasciitis of the scrotum, perineum, and lower abdomen is called Fournier's gangrene. Many patients with Fournier's gangrene are immunosuppressed due to underlying diseases such as diabetes mellitus, obesity or long-term steroid use. Anal fistulae and perianal abscesses are often present. Although the diagnosis is often made clinically, ultrasound may be able to identify evolving Fournier's gangrene before it becomes clinically obvious. Once the diagnosis is established, CT can be utilized to help to determine the initiating focus of infection, and to help plan surgical debridement.
Key Issues: Fournier's gangrene is a rare form of necrotizing fasciitis involving the perineo-scrotal region. Delay in diagnosis increases morbidity and mortality. We review the spectrum of findings on plain radiographs, ultrasound and CT as well as provide background on the etiology and pathology of this rare but clinically significant disease.
Format: Utilizing an educational PowerPoint style format, the many appearances of Fournier's gangrene under different imaging modalities, plain radiograph, U/S, and CT will be presented in a didactic format. The corresponding pathological basis for these findings will also be presented.
Teaching Points: Reviewing the pathological and imaging basis of Fournier's gangrene will familiarize and educate the practicing radiologists and residents in the 1) etiology, pathology, prognosis and complications of Fournier's gangrene 2) the common radiological appearances and finally 3) allow the ability to comfortably diagnosis this condition with a variety of imaging modalities.
E219. Fournier's Gangrene: Imaging Features
Singh A.K.; Radiology, University of Massachusetts Medical Center, Worcester, MA.
Address correspondence to A.K. Singh (asingh1{at}partners.org)
Background: Fournier's gangrene is a rapidly spreading soft tissue infection, the optimum management of which requires early diagnosis, aggressive resuscitation and surgical exploration and debridement. Early clinical and imaging identification of Fournier's gangrene is imperative to avoid delay in the surgical debridement, antibiotic therapy and sometimes hyperbaric oxygen treatments. CT evaluation prior to surgery is recommended in patients with Fournier's gangrene to make early diagnosis and determine the extent of the disease. Early diagnosis can prevent orchidectomy, faecal diversion, loss of muscles and intraperitoneal spread.
Key Issues: The exhibit will comprehensively discuss the CT imaging features of Fournier's gangrene. Radiographic and US findings will also be briefly discussed.
Format: This exhibit is directed towards practicing radiologists and demonstrates the CT imaging features of early and late stage Fournier's gangrene. The extension of the disease process to involve scrotum, penis, perineum, skeletal muscles and intraperitoneal structures will be depicted.
Teaching Points: The viewer will learn: 1. The role of imaging in making early diagnosis. 2. The imaging findings of Fournier's gangrene seen on CT. 3. The disadvantages and limitations of assessment by radiographic and US. 4. Postoperative imaging findings of Fournier's gangrene.
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