Appendiceal Goblet Cell Carcinoma: Role of Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Goblet cell carcinoma (GCC) encompasses a separate entity in appendiceal neoplasms with mixed glandular and neuro-endocrine pathological features. GCC mostly presents as an acute appendicitis duo to luminal obstruction or as an incidental finding on the surgical appendectomy specimen. In case of tumour perforation or presence of other risk factors, guidelines suggest additional treatment with a completing right hemicolectomy or cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). We report the case of a 77-year-old male with symptoms of appendicitis for which an appendectomy was performed. The appendix was ruptured during the procedure. There was an incidental finding of GCC on the pathological specimen. Because of possible tumour soiling, the patient received a prophylactic CRS-HIPEC. A literature review was performed to investigate the potential role for CRS-HIPEC as a curative treatment in patients with GCC. GCC of the appendix is an aggressive type of tumour with a high risk of peritoneal and systemic dissemination. CRS and HIPEC is a treatment option: both in a prophylactic setting and in patients with established peritoneal metastases.

Hepatic rhabdomyosarcoma in an adult: a rare primary malignant liver tumor. Case report and literature review

Rhabdomyosarcomas are malignant tumors that display features of striated muscle differentiation. They are the most common soft-tissue sarcomas among children and young adults. In mature adults however there are very rare. The liver as a primary site in adults has only been described in 12 cases. We report a case of a primary alveolar rhabdomyosarcoma of the liver in a 59 year old female, confirmed by histological examination using immunohistochemical analysis (positive actin, desmin, vimentin and myogenin staining) and fluorescent in situ hybridization (FISH) analysis (positivity for PAX3/FOXO1A fusion). The patient underwent primary surgical resection, but presented a few weeks after surgery already with recurrent disease in the abdomen and bone metastasis. Despite initial good response to chemotherapy (doxorubicin/ifosfamide) and stable disease at 12 months after diagnosis, the patient died 31 months after the first presentation secondary to complicated abundant abdominal recurrent disease. We further present a review of the literature on published similar cases since 1979.

Fat containing adrenal cavernous haemangioma: CT and MRI findings

We report a case of fat containing adrenal cavernous haemangioma. Abdominal computed tomography images showed a large adrenal mass with calcifications and small well demarcated islets of intralesional fat. Magnetic resonance images confirmed the presence of fat and furthermore demonstrated the peripheral spotty contrast enhancement with centripetal enhancement, assuming the possibility of cavernous haemangioma.The histological specimen confirmed cavernous haemangioma of the adrenal gland.

Interlobar Venous Flow Is Different between Left and Right Kidney in Uncomplicated Third Trimester Pregnancy

AIM

To investigate Doppler flow patterns of renal interlobar veins (RIV) in left (L) and right (R) kidney in relation to gestational age and to intrarenal pyelocalyceal diameters (PCD).

METHODS

Cross-sectional study involving 6 groups of women: (1) non-pregnant women, women pregnant between weeks (2) 11-14, (3) 18-23, (4) 28-33, (5) 37-40 and (6) women <5 days post delivery. During standardized renal duplex ultrasound scan, PCD (mm) was measured and venous impedance index (VI = [peak flow (PV) - presystolic flow]/PV) of RIV was defined. Comparison between L and R kidney was performed by repeated-measures analysis of variance for VI and by t tests for PCD.

RESULTS

A total of 150 women were examined, 25 in each group. In the early third trimester of pregnancy, L VI was significantly higher than R VI (0.38 +/- 0.01 vs. 0.33 +/- 0.01, p < 0.0001) and L PCD was significantly lower than R PCD (3.90 +/- 3.68 vs. 6.25 +/- 4.03, p = 0.03).

CONCLUSION

RIV Doppler flow is different between left and right kidney only in the third trimester of pregnancy. This difference is inversely related to PCD, which may be explained by pelvic compression from the gravid uterus.

Oro-facio-digital syndrome type 1: imaging findings in an 11-year-old girl

We describe a uniquely illustrated case of orofaciodigital syndrome type 1. We document many of the possible features of this disorder in a young girl using multiple imaging modalities. Furthermore, we prove that the cysts in kidney and liver are not in contact with the excretory system using MRI, something that to our knowledge has not been previously reported.

Esophageal intramural pseudodiverticulosis complicated by pneumomediastinum

We report a rare case of esophageal intramural pseudodiverticulosis with perforation of the esophagus. A 32-year-old male presented with acute thoracal pain after a period of vomiting. Computed tomography revealed an important amount of mediastinal free air and small outpouchings in the wall of the esophagus. During the following thoracic surgery procedure no macroscopic site of rupture could be identified. Pseudodiverticulosis was detected during a barium swallow exam of the esophagus 4 weeks later.

Hemangiopericytoma of the ovary

We report on a case of hemangiopericytoma in the pelvis occurring in the left ovary. The tumor was found in a 33-year-old woman with left iliac fossa pain. The lesion was well demarcated and had a diameter of approximately 10 cm. It was surgically resected. Computed tomography and ultrasound revealed an aspecific lesion with round lesion with a smooth contour and intratumoral necrosis. To our knowledge, radiological features of hemangiopericytoma of the ovary have not been reported yet.

Ureteral ectopy in the seminal vesicle associated with cyst formation and renal dysplasia: contribution of 3D-MRI

A case of a congenital anomaly of the urinary tract in a 25-year-old Caucasian male is presented. Preoperative and pathologic findings demonstrated an ectopic ureter which terminated in a seminal vesicle cyst. Both structures formed an abortive common duct at the bladder base. The ipsilateral kidney was dysplastic. Findings on voiding cytourethrography, spiral CT, and MRI are discussed and correlated with pathologic findings. The authors suggest that MRI, especially with the use of 3D sequences, is the examination of choice in the evaluation of a complex congenital urogenital anomaly as presented.

Endometrial ossification and infertility: the diagnostic value of different imaging techniques

We present a case of longstanding secondary subfertility caused by endometrial ossification. Of all diagnostic techniques performed, magnetic resonance imaging and hysterosalpingography did not detect the abnormality. Transvaginal ultrasound and computed tomography clearly showed the endometrial pathology. After successful operative hysteroscopy with removal of the osseous tissue, the patient became pregnant spontaneously within 2 months.

Cystic insulinoma of the pancreas in a patient with myotonic dystrophy: correlation of imaging and pathologic findings

We present a case of cystic islet cell tumor of the pancreas in a 60-year old male with myotonic dystrophy. A cystic lesion was found with a thick peripheral rim, a few intralesional septae and a fluid-debris level on CT and MRI. Image characteristics are compared with the pathological findings. MRI demonstrated the internal architecture of the lesion more clearly.

Peliosis hepatis presenting as a multifocal hepatic pseudotumor: MR findings in two cases

Two cases of pseudotumoral peliosis hepatis are presented with emphasis on MRI findings. One patient had four individual lesions, the other had two. Image characteristics in both were: heterogeneic signal intensity on T1-weighted images (T1WI) with areas of high-, intermediate, and low signal intensity; heterogeneic signal intensity on T2WI with presence of numerous intralesional "cystic" hyperintense areas with a hypointense border. Signal intensities on T1WI were iso- to hypointense in one case and mild central hyperintensities were demonstrated in the other case, probably due to intra-lesional hemorrhage or diffuse accumulation of fresh clotting within the sinusoids. One case demonstrated early enhancement of the peripheral borders in the arterial phase, and both demonstrated enhancement in the portovenous and late phases. One case was studied with Gd-BOPTA and iron oxides and demonstrated enhancement with both products, suggestive for the presence of hepatocytes and Kupffer cells. This is the first report of the use of hepato-specific contrast agents in this entity. Spontaneous regression of the lesions was demonstrated on a follow-up MR examination in one case.

Undescended ovary and unicornuate uterus: simplified diagnosis by the use of clomiphene citrate ovarian stimulation and magnetic resonance imaging (MRI)

BACKGROUND

Although the association between unicornuate uterus and undescended ovaries is well established, little information is available on this entity, suggesting the possibility that many cases are not recognized at all. Consequently, important clinical information is missed in many patients worldwide.

METHODS

During a period of 5 years, eight cases of unicornuate uterus were observed in our infertility clinic. The first three patients received magnetic resonance imaging (MRI) after mild clomiphene citrate (CC) stimulation due to a discrepancy between estradiol levels and follicular growth and because a suspected ectopic ovary could not be visualized on ultrasound. Based on this experience, five consecutive patients were offered MRI after CC stimulation as part of this study.

RESULTS

In five out of eight patients with unicornuate uterus (62.5%) an undescended ovary could be visualized in the upper abdomen. Abdominal ultrasound revealed the ectopic ovary in only two cases. The use of CC stimulation undoubtedly facilitated the diagnosis of the undescended ovary on MRI.

CONCLUSION

It is suggested that MRI after CC stimulation is an excellent non-invasive method to diagnose undescended ovaries in women with a unicornate uterus.

Proximal pulmonary artery aneurysm

The authors report on a case of proximal pulmonary artery aneurysm detected on a routine chest X-ray. The scintigraphic and angiographic features of the condition are described and the importance of including the entity in the differential diagnosis of lung masses is stressed.

Midgut volvulus in an adult patient

The authors report on a case of midgut volvulus in a 27-year-old man who presented with bilious vomiting and acute abdominal pain. US demonstrated a reversal of the normal relationship between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV). A clockwise whirlpool sign, diagnostic for midgut volvulus, was not visualised. In a further assessment, upper gastrointestinal series demonstrated obstruction in the second part of the duodenum highly suspicious of Ladd's bands. Malpositioning of bowel structures, as already suggested by the reversal of the SMA and SMV on ultrasound, and a distinctive whirl pattern due to the bowel wrapping around the SMA was demonstrated on CT. Furthermore angiography revealed focal twisting of the SMA. US is the first imaging modality to perform in suspicion of midgut volvulus. When inconclusive, CT is in our opinion the next stage in the diagnostic work-up.

Renal macronodular tuberculoma: CT and MR findings in an asymptomatic patient

We present the case of a 50-year-old man with a solitary mass lesion in the right kidney. Characteristics on ultrasound were a thick irregular hypoechoic wall and a slightly hyperechoic center. Computed tomography depicted the lesion as spontaneously hyperdense at its base. After administration of intravenous iodinated contrast only partial enhancement in the peripheral wall was seen. On MR imaging the lesion was hypointense on T1-weighted images, and T2-weighted images demonstrated a thick irregular hypointense peripheral wall and an intralesional fluid debris level. Gadolinium-chelates were not administered.

MRI in the assessment of pregnancy related intrauterine bleeding: a valuable adjunct to ultrasound?

MR imaging using ultrafast MR sequences is a useful method in assessing pregnancies at risk. This is especially the case for fetal imaging. However, reports of imaging of the placenta or the uterus are rare. We report the MR findings in 8 pregnant patients with vaginal blood loss in whom the obstetrical ultrasound was equivocal. MR imaging was performed with a 1.5 T magnet and consisted of T2- (HASTE), fat-suppressed gradient echo T1- and gradient echo T2-weighted images. Adequate anatomical visualisation of the uterus, the placentary tissue and the intrauterine bleeding irrespective of size and location of the latter, were obtained in all cases.

Omphalocele: prenatal MR findings

We present the MR-findings in two cases of omphalocele in two second trimester pregnancies. Fast MR sequences were performed on a 1.5 T magnet. Both patients underwent previous evaluation with sonography. The findings were confirmed with MR and additional information about the severity and location of the anomaly were demonstrated. The MR images provided adequate anatomical detail of the major abdominal viscera to evaluate the content and extent of the disease.

Diffusion-weighted MR imaging in the evaluation of renal infection: preliminary results

Diffusion-weighted (DW) magnetic resonance imaging (MRI) has already gained status in the neuroradiological MRI approach of a patient suffering from a variety of neurological diseases. The clinical application of DW MRI in the evaluation of renal disease is not standard. This manuscript describes preliminary results of the application of DW imaging in renal infection to aid differential diagnosis and/or lesion detection in clinical MRI. Three patients with acute pyelonephritis and two patients with renal abscess (one with xanthogranulomatous pyelonephritis, the other with a solitary pyogenic renal abscess) were examined with MRI. Areas of acute pyelonephritis and abscedation have restricted proton diffusion and are demonstrated on the DW images. Refinement of the technique, in-depth investigation of the pathological background of the MR findings and evaluation of its true clinical value need further investigation. This manuscripts shows preliminary findings of DW imaging in patients with renal infectious disease.

Granulomatous renal pseudotumor in Wegener's granulomatosis: imaging findings in one case

Wegener's granulomatosis is a clinicopathological entity characterized by necrotizing granulomatous angiitis involving the upper- and/or lower respiratory tract and the kidneys. Renal involvement is usually characterized by a rapidly progressive necrotizing glomerulonephritis. A case is presented of a patient who developed renal failure and presented a solitary pseudotumoral lesion in the upper pole of the left kidney. Imaging characteristics on US, CT and MR imaging are discussed. The diagnosis was confirmed with ultrasound-guided needle biopsy.

Renal infarction as a cause of acute flank pain

Renal infarction results from occlusion of the main renal artery or its distal branches. The clinical picture depends on the extent and the rapidity of the occlusion. Herein, the different imaging modalities (including ultrasonography, computed tomography, magnetic resonance imaging, intravenous urography, and angiography) for diagnozing renal infarction are discussed. The key-modality is computed tomography. Because of the limited warm ischemia time of the kidneys (1.5 hours?) and the time required for diagnosis, there is no real therapeutic relevance in most cases.

Xanthogranulomatous pyelonephritis: MRI findings in the diffuse and the focal type

Two cases of xanthogranulomatous pyelonephritis (XGP) are presented with emphasis on MR appearances. One case is the diffuse type of XGP secondary to chronic obstruction caused by transitional cell carcinoma of the renal pelvis. The other case is the focal or "tumefactive" type of XGP which mimics renal cell carcinoma.

Bilateral xanthogranulomatous perinephritis without renal parenchymal involvement

A case of isolated bilateral xanthogranulomatous perinephritis, which presented as a symmetrical irregular perirenal rim of soft tissue, is reported. Differential diagnosis and image features on ultrasound, computed tomography, and magnetic resonance are discussed.

The contribution of magnetic resonance imaging to the three-dimensional treatment planning of localized prostate cancer

PURPOSE

To investigate whether the use of transaxial and coronal MR imaging improves the ability to localize the apex of the prostate and the anterior part of the rectum compared to the use of transaxial CT alone, and whether the incorporation of MR could improve the coverage of the prostate by the radiotherapy field and change the volume of rectum irradiated.

METHODS AND MATERIALS

Ten consecutive patients with localized prostate carcinoma underwent a CT and an axial and coronal MR scan in treatment position. The CT and MR images were mathematically aligned, and three observers were asked to contour independently the prostate and the rectum on CT and on MR. The interobserver variability of the prostatic apex location and of the delineation of the anterior rectal wall were assessed for each image modality. A dosimetry study was performed to evaluate the dose to the rectum when MR was used in addition to CT to localize the pelvic organs.

RESULTS

The interobserver variation of the prostatic apex location was largest on CT ranging from 0.54 to 1.07 cm, and smallest on coronal MR ranging from 0.17 to 0.25 cm. The interobserver variation of the delineation of the anterior rectum on MR was small and constant along the whole length of the prostate (0.09+/-0.02 cm), while for CT it was comparable to that for the MR delineation at the base of the prostate, but it increased gradually towards the apex, where the variation reached 0.39 cm. The volume of MR rectum receiving more than 80% of the prescribed dose was on average reduced by 23.8+/-11.2% from the CT to the MR treatment plan.

CONCLUSION

It can be concluded that the additional use of axial and coronal MR scans, in designing the treatment plan for localized prostate carcinoma, improves substantially the localization accuracy of the prostatic apex and the anterior aspect of the rectum, resulting in a better coverage of the prostate and a potential to reduce the volume of the rectum irradiated to a high dose.

Giant fibrovascular polyp of the esophagus

We report on a patient who presented a fibrovascular polyp of the esophagus, which is an uncommon submucosal tumor that can attain giant proportions. It is covered with squamous epithelium and consists of a mixture of myxoid-collagenous fibrous elements, vascular structures and adipose cells. Diagnosis is made via upper endoscopy, echoendosonography and barium studies. CT and MR imaging can be helpful for full evaluation of this rare lesion.

Amiodarone induced pulmonary toxicity

We report on a case of complicated long-term amiodarone therapy. CT demonstrated high attenuation pleural-parenchymal lesions and increased liver and spleen density. This article stresses the important role of CT in the diagnosis of amiodarone related disease.