Non-oncologic applications of diffusion-weighted imaging (DWI) in the genitourinary system

Diffusion tensor imaging and fiber tractography of the epididymis in men with non-obstructive azoospermia

BACKGROUND

Scrotal magnetic resonance imaging, including diffusion tensor imaging and fiber tractography has emerged as a valuable, non-invasive method in the evaluation of non-obstructive azoospermia. The epididymis has a crucial role in male infertility.

OBJECTIVES

To evaluate the role of diffusion tensor imaging and fiber tractography of the epididymis in the work-up of non-obstructive azoospermia.

MATERIALS AND METHODS

This prospective study included 22 men with non-obstructive azoospermia and 15 controls. Scrotal magnetic resonance imaging, including diffusion tensor imaging, was performed. The epididymal apparent diffusion coefficient and fractional anisotropy were measured. Fiber tractography reconstructions were created. Non-parametric statistics compared apparent diffusion coefficient and fractional anisotropy of the epididymis between: (1) non-obstructive azoospermia and normal men; (2) histologic phenotypes of non-obstructive azoospermia; (3) non-obstructive azoospermia men, with positive and negative sperm retrieval; and (4) non-obstructive azoospermia men, with idiopathic and non-genetic etiology. Visual assessment of the epididymal fiber tracts was performed.

RESULTS

Lower epididymal fractional anisotropy (p = 0.027) was observed in men with non-obstructive azoospermia in comparison to normal population. Fractional anisotropy decreased (p = 0.033) in cases with idiopathic non-obstructive azoospermia in comparison to men with non-genetic etiology. Fiber tractography showed abnormalities in epididymal fiber tracts in men with non-obstructive azoospermia, including decrease in number and/or thickness and disorganization. However, diffusion tensor imaging parameters were unable to differentiate the histologic types of non-obstructive azoospermia and to predict the results of sperm retrieval (p > 0.05).

DISCUSSION AND CONCLUSION

Our preliminary observations showed that diffusion tensor imaging and fiber tractography of the epididymis provide valuable, non-invasive biomarkers in the work-up of non-obstructive azoospermia, although the clinical significance of these findings is yet to be determined. However, diffusion tensor imaging data were not predictive for the presence of spermatozoa before microdissection testicular sperm extraction.

3.0 T diffusion tensor imaging and fiber tractography of the testes in nonobstructive azoospermia

PURPOSE

To assess the role of 3.0 T Diffusion Tensor Imaging (DTI) and Fiber Tractography (FT) of the testes in the work-up of nonobstructive azoospermia (NOA).

METHODS

This prospective study included consecutive NOA men and controls. A 3.0 T scrotal MRI was performed, including DTI. The testicular apparent diffusion coefficient (ADC) and fractional anisotropy (FA) were calculated. FT reconstructions were created. The Kruskal-Wallis test, followed by pairwise comparisons, assessed differences in testicular ADC and FA between NOA histologic phenotypes (group 1: hypospermatogenesis; group 2: maturation arrest; and group 3: Sertoli cell-only syndrome) and normal testes. The Mann-Whitney-U test compared ADC and FA between NOA testes with positive and negative sperm retrieval. Visual assessment of the testicular fiber tracts was performed. Fiber tracts fewer in number, of reduced thickness, disrupted and/or disorganized were considered "abnormal". Chi-square tests and binary logistic regression analysis assessed variations in testicular fiber tracts morphology.

RESULTS

Twenty-nine NOA men (mean age: 39 ± 5.93 years) and 20 controls (mean age: 26 ± 5.83 years) were included for analysis. Higher ADC (p < 0.001) and FA (p < 0.001) was observed in NOA testes compared to controls. Differences in FA were found between groups 1 and 3 (0.07 vs 0.10, p = 0.26) and groups 2 and 3 (0.07 vs 0.10, p = 0.03), but not between groups 1 and 2 (p = 0.66). An increase in FA was observed in NOA testes with Sertoli cell-only syndrome compared to hypospermatogenesis and maturation arrest. FA was higher in NOA testes with negative results for the presence of sperm compared to those with positive results (0.09 vs 0.07, p = 0.006). FT showed "abnormal" fiber tracts in NOA testes (p < 0.001).

CONCLUSION

3.0 T DTI and FT provide an insight into deranged spermatogenesis in NOA testes.

Diffusion tensor imaging and fiber tractography of the normal epididymis

PURPOSE

To evaluate the feasibility of diffusion tensor imaging (DTI) and fiber tractography (FT) of the normal epididymis and to determine normative apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values.

METHODS

Twenty-eight healthy volunteers underwent MRI of the scrotum, including DTI on a 3.0 T system. For each anatomic part of the epididymis (head, body and tail) free-hand regions of interest were drawn and the mean ADC and FA were measured by two radiologists in consensus. Parametric statistical tests were used to determine intersubject differences in ADC and FA between the anatomic parts of each normal epididymis and between bilateral epididymides. Fiber tracts of the epididymis were reconstructed using the MR Diffusion tool.

RESULTS

The mean ADC and FA of the normal epididymis was 1.31 × 10-3 mm2/s and 0.20, respectively. No differences in ADC (p = 0.736) and FA (p = 0.628) between the anatomic parts of each normal epididymis were found. Differences (p = 0.020) were observed in FA of the body between the right and the left epididymis. FT showed the fiber tracts of the normal epididymis. Main study's limitations include the following: small number of participants with narrow age range, absence of histologic confirmation and lack of quantitative assessment of the FT reconstructions.

CONCLUSION

DTI and FT of the normal epididymis is feasible and allow the noninvasive assessment of the structural and geometric organization of the organ.

Adnexal masses characterized on 3 tesla magnetic resonance imaging - added value of diffusion techniques

Background

To assess different types of adnexal masses as identified by 3T MRI and to discuss the added value of diffusion techniques compared with conventional sequences.

Patients and methods

174 women age between 13 and 87 underwent an MRI examination of the pelvis for a period of three years. Patients were examined in two radiology departments – 135 of them on 3 Tesla MRI Siemens Verio and 39 on 3 Tesla MRI Philips Ingenia. At least one adnexal mass was diagnosed in 98 patients and they are subject to this study. Some of them were reviewed retrospectively. Data from patients’ history, physical examination and laboratory tests were reviewed as well.

Results

124 ovarian masses in 98 females’ group of average age 47.2 years were detected. Following the MRI criteria, 59.2% of the cases were considered benign, 30.6% malignant and 10.2% borderline. Out of all masses 58.1% were classified as cystic, 12.9% as solid and 29% as mixed. Оf histologically proven tumors 74.4% were benign and 25.6% were malignant. All of the malignant tumors had restricted diffusion. 64 out of all patients underwent contrast enhancement. (34 there were a subject of contraindications). 39 (61%) of the masses showed contrast enhancement.

Conclusions

Classifying adnexal masses is essential for the preoperative management of the patients. 3T MRI protocols, in particular diffusion techniques, increase significantly the accuracy of the diagnostic assessment.

Multimodality imaging review for suspected ovarian torsion cases in children

OBJECTIVES

Ovarian torsion (OT), although rare, can be described as a complete or partial twist of the ovary with impairment of blood flow. Although occurring at any age, it is more common in children and during pregnancy. Presenting symptoms are non-specific but include either persistent or intermittent acute abdominal pain, making early diagnosis difficult. Delayed diagnosis is associated with an increased need for oophorectomy. The aim of this literature review is to establish the safest and most efficacious imaging strategy for OT by comparing and contrasting evidence for current imaging modalities found in the literature.

KEY FINDINGS

Characteristically, OT can be identified through a combination of findings some of which includes an enlarged ovary, multiple follicles at the periphery and a "whirlpool" sign. Currently, ultrasound is the preferred primary imaging modality; although computed tomography (CT) and magnetic resonance imaging (MRI) may also be used when findings are equivocal; with MRI being the safer option.

CONCLUSION

Ultimately, while it is true that ovarian torsion is not a common cause of acute abdominal pain in children, it should always be considered in the differential diagnosis. Prior to selecting an imaging modality; the clinical presentation, age group, possible radiation dose and availability of the modality needs to be considered to ensure the appropriate imaging strategy.

IMPLICATIONS FOR PRACTICE

With new tools such as scoring systems, B-flow imaging (BFI), diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) currently being explored for possible use in the future, early diagnosis of OT may be attainable. Thus, reducing the likelihood of adverse complications and consequently the need for oophorectomy.

Benign ovarian lesions with restricted diffusion

Developments in magnetic resonance imaging have expanded its role in the assessment of the female pelvis, including the diagnosis of ovarian lesions. In this setting, diffusion-weighted imaging has proven its diagnostic value, which is particularly important in differentiating between benign and malignant ovarian tumors. In general, the latter show restricted diffusion, whereas the former do not. Exceptions include teratomas, endometriomas, hemorrhagic cysts, ovarian abscesses, ovarian infarction, and some benign stromal tumors. The aim of this review is to draw attention to benign ovarian lesions with restricted diffusion, with a special focus on diffusion-weighted imaging pearls and pitfalls.

Pitfalls of diffusion-weighted imaging of the female pelvis

Diffusion-weighted imaging (DWI) is widely used in protocols for magnetic resonance imaging (MRI) of the female pelvis. It provides functional and structural information about biological tissues, without the use of ionizing radiation or intravenous administration of contrast medium. High signal intensity on DWI with simultaneous low signal intensity on apparent diffusion coefficient maps is usually associated with malignancy. However, that pattern can also be seen in many benign lesions, a fact that should be recognized by radiologists. Correlating DWI findings with those of conventional (T1- and T2-weighted) MRI sequences and those of contrast-enhanced MRI sequences is mandatory in order to avoid potential pitfalls. The aim of this review article is the description of the most relevant physiological and benign pathological conditions of the female pelvis that can show restricted diffusion on DWI.

Imaging patients with renal impairment

Imaging with intravascular contrast media is generally considered safe, particularly in patients without renal failure. However, as renal function deteriorates, the potential risk of nonallergic-type adverse events increases. This presents a unique challenge, particularly when the use of intravenous contrast media is deemed essential for diagnostic purposes. Following a discussion regarding the definition and epidemiology of kidney injury, this review focuses on the evolving understanding of both contrast-induced nephropathy and nephrogenic systemic fibrosis and discusses preventative strategies aimed at minimizing the risk of developing these entities. Alternative non-contrast imaging techniques are also discussed.