Lung cancer screening in Brazil: recommendations from the Brazilian Society of Thoracic Surgery, Brazilian Thoracic Association, and Brazilian College of Radiology and Diagnostic Imaging

Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

Practical Guide to VI-RADS: MRI Protocols, Lesion Characterization, and Pitfalls

Urothelial carcinoma is the most common type of bladder cancer (BC), accounting for approximately 90% of all cases. Evaluating the depth of tumor invasion in the bladder wall (tumor staging) is essential for determining the treatment and prognosis in patients with BC. Neoadjuvant therapy followed by radical cystectomy is the most common treatment of localized muscle-invasive BC (MIBC). Therefore, it is vital to differentiate non-MIBC from MIBC. Transurethral resection of bladder tumor (TURBT) is the reference standard to determine the extent of tumor invasion into the bladder wall through tissue sampling. However, this diagnostic and therapeutic method may not adequately sample the muscularis propria, leading to a higher risk of residual disease, early recurrence, and tumor understaging in approximately 50% of patients during the initial TURBT. Multiparametric MRI can overcome some of the limitations of TURBT when evaluating BC, particularly regarding tumor staging. In this context, the Vesical Imaging Reporting and Data System (VI-RADS) classification was developed to establish standards for bladder multiparametric MRI and interpretation. It uses a 5-point scale to assess the likelihood of detrusor muscle invasion. T2-weighted MR images are particularly useful as an initial guide, especially for categories 1-3, while the presence of muscular invasion is determined with diffusion-weighted and dynamic contrast-enhanced sequences. Diffusion-weighted imaging takes precedence as the dominant method when optimal image quality is achieved. The presence of a stalk or a thickened inner layer and no evidence of interruption of the signal intensity of the muscular layer are central for predicting a low likelihood of muscle invasion. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Hoegger in this issue.

Establishing national clinical diagnostic reference levels and achievable doses for CT examinations in Brazil: A prospective study

PURPOSE

Diagnostic reference levels (DRL) and achievable doses (AD) are important tools for radiation dose optimization. Therefore, a prospective study was performed which aimed to establish a multi-parametric, clinical indication based - DRL(DRLCI) and clinical indication - AD (ADCI) for adult CT in Brazil.

METHODS

The prospective study included 4787 patients (50 ± 18 years old; male:female 2041:2746) at 13 Brazilian sites that have been submitted to head, paranasal sinus, cervical spine, chest, or abdomen-pelvis CT between January and October 2021 for 13 clinical indications. The sites provided the following information: patient age, gender, weight, height, body mass index[BMI], clinical indications, scanner information(vendor, model, detector configuration), scan parameters (number of scan phases, kV, mA, pitch) and dose-related quantities (CT dose index volume- CTDIvol, dose length product- DLP). Median(AD) and 75th(DRL) percentile CTDIvol and DLP values were estimated for each body region and clinical indications. Non-normal data were analyzed with the Kruskal-Wallis test.

RESULTS

In majority of Brazilian sites, body region and clinical indications based DRLs were at or lower than the corresponding DRLs in the US and higher than Europe. Although radiation doses varied significantly for patients in different body mass index groups (p < 0.001), within each body region, there were no differences in radiation doses for different clinical indications (p > 0.1). Radiation doses for 7/13 clinical indications were higher using iterative reconstruction technique than for the filtered back projection.

CONCLUSIONS

There was substantial variation in Brazil DRLCI across different institutions with higher doses compared to the European standards. There was also a lack of clinical indication-based protocol and dose optimization based on different clinical indications for the same body region.

VI-RADS score system - A primer for urologists

Bladder cancer (BCa) is one of the most common cancers worldwide and is also considered to be one of the most relapsing and aggressive neoplasms. About 30% of patients will present with muscle invasive disease, which is associated with a higher risk for metastatic disease. The aim of this article is to review the state of art imaging in Radiology, while providing a complete guide to urologists, with case examples, for the rationale of the development of the Vesical Imaging Reporting and Data System (VI-RADS), a scoring system emphasizing a standardized approach to multiparametric Magnetic Resonance Imaging (mpMRI) acquisition, interpretation, and reporting for BCa. Also, we examine relevant external validation studies and the consolidated literature of mpMRI for bladder cancer. In addition, this article discusses some of the potential clinical implications of this scoring system for disease management and follow-up.

Frequency of lipid-poor adrenal adenomas in magnetic resonance imaging examinations of the abdomen

Objective

To estimate the frequency of lipid-poor adenomas (LPAs) in magnetic resonance imaging (MRI) examinations.

Materials and Methods

We retrospectively investigated adrenal lesions on MRI examinations performed in a total of 2,014 patients between January 2016 and December 2017. After exclusions, the sample comprised 69 patients with 74 proven adenomas. Two readers (reader 1 and reader 2) evaluated lesion size, laterality, homogeneity, signal drop on out-of-phase (OP) images, and the signal intensity index (SII). An LPA was defined as a lesion with no signal drop on OP images and an SII < 16.5%. For 68 lesions, computed tomography (CT) scans (obtained within one year of the MRI) were also reviewed.

Results

Of the 69 patients evaluated, 42 (60.8%) were women and 27 (39.2%) were men. The mean age was 59.2 ± 14.1 years. Among the 74 confirmed adrenal adenomas evaluated, the mean lesion size was 18.5 ± 7.7 mm (range, 7.0-56.0 mm) for reader 1 and 21.0 ± 8.3 mm (range, 7.0-55.0 mm) for reader 2 (p = 0.055). On the basis of the signal drop in OP MRI sequences, both readers identified five (6.8%) of the 74 lesions as being LPAs. When determined on the basis of the SII, that frequency was three (4.0%) for reader 1 and four (5.4%) for reader 2. On CT, 21 (30.8%) of the 68 lesions evaluated were classified as LPAs.

Conclusion

The prevalence of LPA was significantly lower on MRI than on CT. That prevalence tends to be even lower when the definition of LPA relies on a quantitative analysis rather than on a qualitative (visual) analysis.

Análise dos materiais didáticos utilizados por radiologistas e residentes de radiologia brasileiros: mudança de paradigma

Resumo Objetivo: Identificar o perfil de utilização dos recursos didáticos pelos médicos radiologistas e residentes em radiologia e diagnóstico por imagem brasileiros. Materiais e Métodos: Estudo observacional, transversal e descritivo, realizado por meio de questionário eletrônico contendo perguntas referentes ao perfil do médico, formação, local de atuação, perfil de acesso a recursos educacionais e tipos de recursos mais utilizados. Resultados: Responderam ao questionário 265 médicos com idade média de 38,2 anos, sendo a maioria radiologistas formados (170; 64,2%), do sexo masculino (166; 62,6%), trabalhando em instituições privadas (174; 65,7%), sem vínculo acadêmico (167; 63,0%), atuando principalmente nas áreas de ultrassonografia (212; 80,0%) e tomografia computadorizada (206; 77,7%). A carga horária média de estudo semanal foi de 9,6 horas (mediana: 6 horas), sendo maior no grupo dos médicos que estão em formação e nos que atuam em instituições públicas e acadêmicas. Quanto ao recurso para o acesso do material de estudo, observou-se uma tendência pela maior utilização do computador (65,3%). A maioria dos respondentes optou por acessar materiais didáticos sem custo (61,9%), sendo os sites da web, livros e revistas eletrônicas os mais pesquisados. Conclusão: Os radiologistas brasileiros utilizam recursos eletrônicos e digitais como principais materiais didáticos, sendo os sites da web, livros e revistas eletrônicas as fontes mais utilizadas.

Xanthogranulomatous pyelonephritis: Case series - Clinical, radiologic, therapeutic, and histological aspects

Purpose

Xanthogranulomatous pyelonephritis (XGP) is a chronic and severe infection of the kidney. We aimed to review the main clinical, imaging, and histological findings and to assess predictors of surgical complications or hospitalization >10 days (no deaths reported).

Materials and Methods

We retrospectively searched all patients with XGP treated at our institution from 2005 to 2019, with 57 patients enrolled. Clinical data were retrieved by a single reader, computed tomographic (CT) examinations by two radiologists, and histopathological specimens by an experienced pathologist.

Results

The patients' mean age was 44.3 ± 16.2 years and 41 (71.9%) were female. The most common symptoms were flank/lumbar pain (89.5%), fever (43.9%), and recurrent urinary tract infection (43.9%). The mean time until the presumptive diagnosis was 365.1 days and the median hospitalization period was 11 days. Blood tests showed anemia (78.9%), leukocytosis (43.6%) with left shift (21.6%). Urinalysis showed hematuria (75.6%), bacteriuria (40.9%), and leukocytes (93.2%). Urine cultures showed Escherichia coli in 14.8%, Proteus mirabilis in 7.4%, while 59.3% were negative. Of 40 patients with CT examinations, 38 (95%) presented with hydronephrosis and perinephric inflammatory changes (PIC) and 22 (55%) with Bear Paw sign. PIC was the only independent predictor at multivariate analysis for surgical complications. For prolonged hospitalization, fever and PIC were independent predictors at univariate, but only fever at multivariate analysis.

Conclusions

XGP is a worrisome condition, with unclear pathophysiological mechanisms. Fever and PIC at CT examinations were predictors of poor outcomes.

Communication in radiology: evaluation of terminology and TNM descriptor use at a cancer center

Objective

The purpose of our study was to evaluate the transmission of information from radiologists to physicians, focusing on the level of certainty and the use of imaging descriptors from the tumor-node-metastasis (TNM) staging system.

Materials and Methods

Radiologists (n = 56) and referring physicians (n = 50) participated in this questionnaire-based, singlecenter study, conducted between March 20, 2020, and January 21, 2021. Participants were presented with terms commonly used by the radiologists at the institution and were asked to order them hierarchically in terms of the level of certainty they communicate regarding a diagnosis, using a scale ranging from 1 (most contrary to) to 10 (most favoring). They then assessed TNM system descriptors and their interpretation. Student's t-tests and the kappa statistic were used in order to compare the rankings of the terms of certainty. Items related to T and N staging were analyzed by Fisher's exact test. The confidence level was set to 97% (p < 0.03).

Results

Although overall agreement among the radiologists and referring physicians on term ranking was poor (kappa = 0.10- 0.35), the mean and median values for the two groups were similar. Most of the radiologists and referring physicians (67% and 86%, respectively) approved of the proposal to establish a standard lexicon. Such a lexicon, based on the participant responses, was developed and graphically represented. Regarding the TNM system descriptors, there were significant differences between the two groups in the reporting of lymph node numbers, of features indicating capsular rupture, and of vessel wall irregularities, as well as in the preference for clear descriptions of vascular involvement.

Conclusion

Our findings indicate that ineffective communication and differences in report interpretation between radiologists and referring physicians are still prevalent in the fields of radiology and oncology. Efforts to gain a better understanding of those impediments might improve the objectivity of reporting and the quality of care.

The role of magnetic resonance imaging in active surveillance of prostate cancer

Active surveillance (AS) is an important strategy to avoid overtreatment of prostate cancer (PCa) and has become the standard of care for low-risk patients. The role of magnetic resonance imaging (MRI) in AS has expanded due to its ability to risk stratify patients with suspected or known PCa, and MRI has become an integral part of the AS protocols at various institutions. A negative pre-biopsy MRI result is associated with a very high negative predictive value for a Gleason score ≥ 3+4. A positive MRI result in men who are otherwise eligible for AS has been shown to be associated with the presence of high-grade PCa and therefore with ineligibility. In addition, MRI can be used to guide and determine the timing of per-protocol biopsy during AS. However, there are several MRI-related issues that remain unresolved, including the lack of a consensus and guidelines; concerns about gadolinium deposition in various tissues; and increased demand for higher efficiency and productivity. Similarly, the need for the combined use of targeted and systematic sampling is still a matter of debate when lesions are visible on MRI. Here, we review the current AS guidelines, as well as the accepted roles of MRI in patient selection and monitoring, the potential uses of MRI that are still in question, and the limitations of the method.

Transarterial embolization with n-butyl cyanoacrylate for the treatment of active abdominopelvic bleeding in the polytraumatized patient

PURPOSE

An increasing number of polytraumatized patient presenting with active abdominal pelvic bleeding (APB) have been treated by endovascular selective embolization. However, reports on evaluate the efficacy, safety and complications caused by this technique have been limited. The aim of this study was to assess the safety and efficacy of embolization of APB using N-butyl cyanoacrylate glue (NBCA).

MATERIALS AND METHODS

Single center retrospective study, that included consecutive 47 patients presenting with traumatic APB treated by embolization with NBCA between January 2013 and June 2019. The efficacy endpoint was defined as the absence of contrast extravasation immediately after procedure and clinical stabilization in the following 24 h after procedure. Clinical stabilization was defined as no rebleeding after embolization or the need for a surgical approach until the patient is discharged. Safety endpoint were any technical or clinical complications related to the embolization procedure.

RESULTS

The mean age of patients was 38.6 years (3-81), with a predominance of males (87.2%). The major causal factor of APB being involvement in a car accident, accounting for 68% of cases. Of the 47 cases, 29.8% presented pelvic trauma and the remaining (70.2%) presented abdominal trauma. The efficacy rate was 100%, while no complications related to the procedure were observed. The mortality rate was 14.8% (7/47) due to neurologic decompensation and other clinical causes.

CONCLUSION

Endovascular embolization of traumatic abdominopelvic bleedings appear to be a highly safe and effective treatment, while avoiding emergent exploratory open surgeries.

An international expert opinion statement on the utility of PET/MR for imaging of skeletal metastases

BACKGROUND

MR is an important imaging modality for evaluating musculoskeletal malignancies owing to its high soft tissue contrast and its ability to acquire multiparametric information. PET provides quantitative molecular and physiologic information and is a critical tool in the diagnosis and staging of several malignancies. PET/MR, which can take advantage of its constituent modalities, is uniquely suited for evaluating skeletal metastases. We reviewed the current evidence of PET/MR in assessing for skeletal metastases and provided recommendations for its use.

METHODS

We searched for the peer reviewed literature related to the usage of PET/MR in the settings of osseous metastases. In addition, expert opinions, practices, and protocols of major research institutions performing research on PET/MR of skeletal metastases were considered.

RESULTS

Peer-reviewed published literature was included. Nuclear medicine and radiology experts, including those from 13 major PET/MR centers, shared the gained expertise on PET/MR use for evaluating skeletal metastases and contributed to a consensus expert opinion statement. [18F]-FDG and non [18F]-FDG PET/MR may provide key advantages over PET/CT in the evaluation for osseous metastases in several primary malignancies.

CONCLUSION

PET/MR should be considered for staging of malignancies where there is a high likelihood of osseous metastatic disease based on the characteristics of the primary malignancy, hight clinical suspicious and in case, where the presence of osseous metastases will have an impact on patient management. Appropriate choice of tumor-specific radiopharmaceuticals, as well as stringent adherence to PET and MR protocols, should be employed.

Estrogen-secreting adrenocortical tumor in a postmenopausal woman: a challenging diagnosis

SUMMARY

Adrenocortical carcinoma (ACC) is a malignant disorder with rapid evolution and severe prognosis in adults and most produce cortisol and androgen. Estrogen-secreting adrenocortical carcinomas are extremely rare, especially in women, tend to be larger and have worse prognosis compared with other types of ACCs. We report the case of a 58-year-old woman who presented with bilateral breast enlargement and postmenopausal genital bleeding. She presented high estradiol (818 pg/mL - 25 times above upper normal limit for postmenopausal women) and testosterone (158 ng/dL - 2 times above upper normal limit) levels and no suppression of cortisol after overnight 1 mg dexamethasone test (12.5 µg/dL; normal reference value: < 1.8 µg/dL). The patient had no clinical features of cortisol excess. MRI showed a 12 cm tumor in the right adrenal. Clinical findings of bilateral breast enlargement and postmenopausal genital bleeding with no signs of hypercortisolism associated with hormonal findings of elevated estradiol and testosterone levels would indicate either an ovarian etiology or an adrenal etiology; however, in the context of plasma cortisol levels non-suppressive after dexamethasone test and the confirmation of an adrenal tumor by MRI, the diagnosis of an adrenal tumor with mixed hormonal secretion was made. The patient underwent an open right adrenalectomy and pathological examination revealed an ACC with a Weiss' score of 6. Estradiol and testosterone levels decreased to normal range soon after surgery. She was put on mitotane treatment as adjuvant therapy, but due to side effects, we were unable to up-titrate the dose and she never achieved serum mitotane dosage above the desired 14 µg/mL. The patient remained in good health without any local recurrence or metastasis until 5 years after surgery, when increased levels of estradiol (81 pg/mL - 2.5 times above upper normal limit) and testosterone (170 ng/dL - 2.1 times above upper normal limit) were detected. MRI revealed a retroperitoneal nodule measuring 1.8 × 1.2 cm. The pathological finding confirmed the recurrence of the estrogen-secreting ACC with a Weiss' score of 6. After the second procedure, patient achieved normal estrogen and androgen serum levels and since then she has been followed for 3 years. The overall survival was 8 years after the diagnosis. In conclusion, although extremely rare, a diagnosis of an estrogen-secreting ACC should be considered as an etiology in postmenopausal women presenting with bilateral breast enlargement, genital bleeding and increased pure or prevailing estrogen secretion.

LEARNING POINTS

Estrogen-secreting adrenocortical carcinomas are exceedingly rare in adults and account for 1-2% of adrenocortical carcinomas. Estrogen-secreting adrenal tumors can be present in females, but are even more rare, we found few cases described in the literature. In women, they present with precocious puberty or postmenopausal bleeding. Feminization in the context of an adrenal tumor is considered almost pathognomonic of malignancy. Feminizing ACCs tend to be larger and with worse prognosis compared with nonfeminizing ACCs.

Transarterial embolization with n-butyl cyanoacrylate for the treatment of abdominal wall hemorrhage

PURPOSE

We aimed to evaluate the effectiveness and safety of n-butyl cyanoacrylate (n-BCA) in the context of the transarterial embolization (TAE) of abdominal wall hemorrhage in an urgent scenario.

METHODS

A retrospective study of cases admitted from January 2008 to December 2017 in the emergency unit of our institution revealed 11 patients with abdominal wall hemorrhage who underwent digital subtraction angiography and TAE with n-BCA. We analyzed the sex, age, hemorrhagic risk factors, etiology, embolized vessel, technical success (no rebleeding in the embolized area), clinical success (hemoglobin level control and hemodynamic stability after the procedure), complications inherent to the procedure, and clinical outcome (mortality in 30 days).

RESULTS

The mean age was 63.4 years (52-83 years), with a predominance of the female sex (64%). The majority (91%) of patients presented hemorrhagic risk factors (chronic hepatopathy and anticoagulation drug usage). Spontaneous hemorrhage was present in 18% of patients, and the other 82% had an iatrogenic etiology. Technical success was achieved in 100% of the patients, which required the embolization of inferior epigastric artery in 10 patients (91%), circumflex iliac artery in 2 (18%), and superior epigastric artery in 1 (9%). Five patients were hemodynamically unstable, and despite achieving technical success, 4 (36%) died in less than 30 days due to decompensation of their clinical comorbidities caused by the acute phase. There were no complications inherent to the procedures.

CONCLUSION

The present study concludes that TAE with n-BCA is a safe and effective treatment for abdominal wall hemorrhage in an urgent scenario, with high rates of technical and clinical success.

Lacrimal gland atrophy and dry eye related to isotretinoin, androgen, and prolactin: differential diagnosis for Sjögren's syndrome

This report is of three cases of sicca syndrome, initially suspected to be Sjögren's syndrome, which was ruled out by clinical and laboratory investigations. The patients were a 24-year-old woman, a 32-year-old man, and a 77-year-old woman with chronic symptoms of sicca syndrome, including dry eye syndrome. The first case was associated with the use of isotretinoin, a retinoic acid. The second was associated with the use of anabolic androgenic steroids, and the third was related to a prolactin- secreting pituitary adenoma. All cases manifested sicca, including dry eye syndrome, after those events, and the manifestations persisted. Magnetic resonance imaging revealed bilateral atrophy of the lacrimal gland. The medical history, ocular examinations, laboratory exams, and magnetic resonance images confirmed dry eye syndrome; however, the exams were all negative for Sjögren's syndrome. The lacrimal gland was absent on magnetic resonance imaging in all three cases. The clinical history revealed that the signs and symptoms appeared after chronic exposure to retinoic acid, anabolic androgenic steroids, and a prolactin-secreting pituitary adenoma, respectively. Chronic isotretinoin, anabolic androgenic steroids, and prolactin-secreting pituitary adenoma or, in this last case, its inhibitory treatment, can cause lacrimal gland atrophy, sicca syndrome, and dry eye syndrome, and a differential diagnosis of Sjögren's syndrome. Further studies on doses, time, and other susceptibilities to the long-lasting adverse effects of retinoic acid, anabolic androgenic steroids, and the repercussions of prolactin-secreting pituitary adenoma are necessary to confirm and expand upon these associations.

Pulmonary Vascular Volume Estimated by Automated Software is a Mortality Predictor after Acute Pulmonary Embolism

Fundamento:

A embolia pulmonar aguda (EPA) tem desfecho clínico variável. A angiotomografia computadorizada (angio-CT) é considerada o padrão-ouro para o diagnóstico.

Objetivo:

Avaliar se o volume vascular pulmonar (VVP) quantificado por software automatizado é um preditor de mortalidade após EPA.

Métodos:

Estudo de coorte retrospectivo no qual a imagem da angio-CT de 61 pacientes com EPA foi reanalisada. O VVP e o volume pulmonar (VP) foram estimados automaticamente pelo software Yacta. Calculamos o VVP ajustado pela razão: VVP(cm³)/VP(litros). Parâmetros prognósticos clássicos da angio-CT (carga embólica; razão do diâmetro do ventrículo direito/ventrículo esquerdo; razão do diâmetro da artéria pulmonar/aorta; desvio do septo interventricular; infarto pulmonar e refluxo de contraste na veia hepática) foram avaliados. A mortalidade em 1 mês foi o desfecho analisado. Consideramos um valor de p <0,05 como estatisticamente significativo.

Resultados:

Sete mortes (11%) ocorreram entre os 61 pacientes durante 1 mês de seguimento. O VVP ajustado <23cm³/L foi um preditor independente de mortalidade na análise univariada (odds ratio [OR]: 26; intervalo de confiança de 95% [IC95%]: 3-244; p=0,004) e na análise multivariada (OR ajustado: 19 [IC95%: 1,3-270]; p=0,03). Os parâmetros clássicos da angio-CT não foram associados à mortalidade em 1 mês nesta amostra. O VVP ajustado <23cm³/L apresentou sensibilidade de 86%, especificidade de 82%, valor preditivo negativo de 94% e valor preditivo positivo de 64% para identificação dos pacientes que morreram.

Conclusão:

VVP ajustado <23cm³/L foi um preditor independente de mortalidade após EPA. Esse parâmetro mostrou melhor desempenho prognóstico do que os outros achados clássicos da angio-CT. (Arq Bras Cardiol. 2020; 115(5):809-818)

The ABCD of portal vein thrombosis: a systematic approach

Portal vein thrombosis refers to complete or partial obstruction of the portal venous system, in the intrahepatic or extrahepatic venous tract or even in the splenic or superior mesenteric veins. This common and potentially fatal condition can develop in various clinical contexts, especially those of liver cirrhosis, hepatocellular carcinoma, and other solid tumors. Certain characteristics, such as the time since the onset of the thrombus (acute or chronic), its biology (hematic or tumoral), the presence of collateral vessels, and the magnetic resonance imaging aspects, are important components of a thorough, careful analysis, as well as informing decisions regarding the appropriate therapeutic strategy. Here, we present a brief review of the anatomy of the portal venous system and a systematic approach to analyzing the condition, using a mnemonic (ABCD, for age, biology, collaterals, and diffusion). We discuss the various imaging methods and illustrate our discussion with images selected from the case files archived at our facility.

Doctor, a patient is on the phone asking about the endorectal coil!

The question referred to in the title of this article is a relatively common situation when performing prostate MRI in some healthcare settings. Moreover, the answer is not always straightforward. The decisions on type of receiver coil for prostate MRI and whether or not an endorectal coil (ERC) should be used is based on several factors. These relate to the patient (e.g., body habitus, presence of metallic devices in the pelvis), the focus of the exam (diagnosis, staging, recurrence), and characteristics of the MRI system (e.g., magnetic field strength and hardware components including coil design and number of elements/channels available in the surface coil). Historically, the combined use of an ERC and a surface coil was the optimal combination for maximizing the signal-to-noise ratio (SNR), particularly for low-strength magnetic fields (1.5T). However, there are several disadvantages associated with the use of an ERC, and several studies have advocated equivalent clinical performance of modern MRI systems for diagnosis and staging of prostate cancer (PCa), either with ERC or surface alone. Accordingly, there is a wide variation in the precise imaging technique across institutions. This article focuses on the most relevant aspects of the decision of whether to use an ERC for PCa MR imaging.

Value of adding the apparent diffusion coefficient to capsular contact for the prediction of extracapsular extension in prostate cancer

Objective

To determine whether evaluating the mean apparent diffusion coefficient (ADC) together with capsular contact (CC) adds value in the prediction of microscopic extracapsular extension (ECE) of prostate cancer.

Materials and Methods

Between January 2012 and December 2016, 383 patients underwent multiparametric magnetic resonance imaging (mpMRI) of the prostate. A total of 67 patients were selected for inclusion. Two radiologists (observers 1 and 2), working independently, performed qualitative and quantitative analyses of ECE, macroscopic ECE, and microscopic ECE. A third radiologist assessed the correlation with the clinical data, and two experienced pathologists reviewed all histopathological findings.

Results

Among the 67 patients, mpMRI showed lesions that were confined to the capsule in 44 (66.7%), had microscopic ECE in 12 (17.9%), and had macroscopic ECE in 11 (16.4%). There were no significant differences, in terms of the diagnostic accuracy, as measured by determining the area under the curve (AUC), of CC on T2-weighted images (CCT2), CC on diffusion-weighted imaging (CCDWI), and the mean ADC for the prediction of microscopic ECE, between observer 1 (AUC of 0.728, 0.691, and 0.675, respectively) and observer 2 (AUC of 0.782, 0.821, and 0.799, respectively). Combining the mean ADC with the CCT2 or CCDWI did not improve the diagnostic accuracy for either observer. There was substantial interobserver agreement for the qualitative evaluation of ECE, as demonstrated by the kappa statistic, which was 0.77 (0.66-0.87). The diagnostic accuracy (AUC) of the qualitative assessment for predicting microscopic ECE was 0.745 for observer 1 and 0.804 for observer 2, and the difference was less than significant. In a multivariate analysis, none of clinical or imaging parameters were found to be associated with ECE.

Conclusion

For the detection of microscopic ECE on mpMRI, CC appears to have good diagnostic accuracy, especially if the observer has considerable experience. Adding the mean ADC to the CCT2 or CCDWI does not seem to provide any significant improvement in that diagnostic accuracy.

Pelvic floor muscles after prostate radiation therapy: morpho-functional assessment by magnetic resonance imaging, surface electromyography and digital anal palpation

Aim:

To evaluate the radiotherapy (RT) effect in the pelvic floor muscles (PFM) function in men with prostate cancer (PC).

Materials and Methods:

A cross-sectional study included three groups of patients with PC and RT indication: 1) Pre-RT group: evaluated before the beginning of RT; 2) Acute group: evaluated between six months and one year after RT; 3) Late Group: evaluated between two and a half years and four years post-RT. PFM assessment was divided into: a) functional assessment through the digital anal palpation (Modified Oxford Scale) and surface electromyography (sEMG) with anal probe; b) anatomical assessment by pelvic magnetic resonance imaging (MRI) with thickness measurements of levator ani muscle and pelvic specific parameters at rest and under Valsalva maneuver. We used Student t test, considering as significant p <0.05.

Results:

Thirty-three men were assessed: Pre-RT (n=12); Acute (n=10) and Late (n=11) groups. PFM functional assessment showed Late group with lower electromyographic activity, especially in the sustained contractions when compared to the Pre-RT (p=0.003) and Acute groups (p=0.006). There was no significant difference between groups in MRI.

Conclusion:

PFM functional assessment showed a decrease in sEMG activity in the Late group post-RT. Most of the sample (72.7%) did not know how to actively contract the PFM or had a weak voluntary contraction when assessed by digital anal palpation. Also, these patients presented higher prevalence of pelvic complaints. No changes were observed in the morpho-functional parameters evaluated by MRI, except the measurement of the membranous urethra length when comparing Pre-RT Group and Acute and Late Groups.

Estimating the productivity of radiologists in Brazil: the search for a benchmark

Objective

To determine the average productivity of radiologists, as measured by number of reports issued per 6-h shift, evaluating variables that could affect the results.

Materials and Methods

This was a study utilizing an online questionnaire sent to radiologists affiliated with the Brazilian College of Radiology and Diagnostic Imaging. The questions were related to the demographic profile and professional practice characteristics (form of remuneration, primary imaging method employed, and subspecialty) of the radiologists, as well as their individual productivity (average personal productivity) and the productivity considered reasonable in a 6-h shift. The association between productivity and the practice characteristics of the radiologists was determined by using Poisson regression to calculate the prevalence ratio.

Results

A total of 510 radiologists completed the questionnaire. The great majority of the respondents (84%) reported that their remuneration is directly related to their productivity. The productivity varied according to the subspecialty, work environment, and remuneration model.

Conclusion

We demonstrated that the productivity of radiologists is associated with the characteristics of their employment. We hope that this study will encourage other studies aimed at evaluating the productive capacity of the radiologists in Brazil, addressing the various functions they perform in their daily routine, including activities other than issuing reports.

Comprehensive radiogenomics analysis of qualitative and quantitative features of cross-sectional imaging in the TCGA project in MIBC

482

Background: Quantitative imaging descriptors derived from CT and MRI can be integrated with genomic data that may be used as non-invasive prognostic or predictive biomarkers. We report an integrated radiogenomics project designed to develop subjective and objective parameters extracted from cross-sectional imaging of MIBC from studies archived in the TCIA and linked to the TCGA project. Methods: We reported comprehensive integrated genomic analysis of 412 tumors (Cell 2017). 7 of 33 tissue source sites submitted CT scans to the TCIA (n=106). We developed 17 features describing tumor size/location, metastases sites, and tumor morphology; 9 GU radiologists reviewed the scans in a blinded manner. EH analyzed the data independent of the radiologists. We computed kappa statistics for categorical features and coverage probabilities for quantitative features (Lin et al 2002). The tumor was segmented on an axial image and the segmented image analyzed using a radiomics panel (radiomicslab.usc.edu). Associations between individual features and subtypes were assessed (Fisher’s Exact Test) for categorical features and Kruskal-Wallis Test for quantitative features. Results: Substantial agreement (k≥ 0.6) was observed in 4 features: tumor laterality, tumor within bladder diverticulum, right and left UVJ involvement and hydroureter. We observed weak agreement (95% CI <0.4) for bladder neck, posterior bladder, dome, and trigone involvement, tumor margin, internal architecture, radiographic stage, left upper tract involvement, and metastases. The coverage probability for lesion size was 0.59 (0.544-0.638) (Figure). Tumor morphology was associated with microRNA cluster, with diffuse wall thickening having a higher tendency toward Clusters 3 and 4 (p < .001). Radiomic analysis identified statistically significant associations of mutations in FGFR3, CREBBP, CASP8 and EP300 with multiple radiomic features. Conclusions: This blinded comprehensive assessment of features extracted from CT images highlights many of the ongoing challenges in staging patients with MIBC. Preliminary analysis shows promise in analyzing associations between radiomic features and mutations.

Minimally Complex Renal Cysts: Outcomes and Ultrasound Evaluation Compared with Contrast-Enhanced Cross-Sectional Imaging Bosniak Classification

We correlated contrast-enhanced cross-sectional imaging and outcomes to assess the reproducibility of ultrasonographic criteria for renal minimally complex (MC) cysts. From 2003 to 2015, 143 cysts were described as complex or MC by ultrasound (US). After exclusions, 98 US studies were retrospectively evaluated and compared with computed tomography (CT)/magnetic resonance imaging (MRI). At sonography, 51 were MC cysts and 47 were complexes according to two independent observers. Inter-observer agreement for US was 0.704 and 0.745 for CT/MRI. Of 51 cysts classified as MC by US, 38 were Bosniak I/II and 6 were Bosniak IIF by CT/MRI. In 7, there were no cross-sectional images; however, they were stable for at least 2 y. Of 47 complex cysts, 9 were Bosniak II, 22 Bosniak IIF, 8 Bosniak III and 8 Bosniak IV. No Bosniak III/IV cysts by CT/MRI were classified as MC by US. Our results indicate that US offers reproducible criteria for MC cysts and may be used alone for these lesions.

Reproducibility of abdominal fat assessment by ultrasound and computed tomography

Objective:

To test the accuracy and reproducibility of ultrasound and computed tomography (CT) for the quantification of abdominal fat in correlation with the anthropometric, clinical, and biochemical assessments.

Materials and Methods:

Using ultrasound and CT, we determined the thickness of subcutaneous and intra-abdominal fat in 101 subjects-of whom 39 (38.6%) were men and 62 (61.4%) were women-with a mean age of 66.3 years (60-80 years). The ultrasound data were correlated with the anthropometric, clinical, and biochemical parameters, as well as with the areas measured by abdominal CT.

Results:

Intra-abdominal thickness was the variable for which the correlation with the areas of abdominal fat was strongest (i.e., the correlation coefficient was highest). We also tested the reproducibility of ultrasound and CT for the assessment of abdominal fat and found that CT measurements of abdominal fat showed greater reproducibility, having higher intraobserver and interobserver reliability than had the ultrasound measurements. There was a significant correlation between ultrasound and CT, with a correlation coefficient of 0.71.

Conclusion:

In the assessment of abdominal fat, the intraobserver and interobserver reliability were greater for CT than for ultrasound, although both methods showed high accuracy and good reproducibility.

Mapping the different methods adopted for diagnostic imaging instruction at medical schools in Brazil

OBJECTIVE

To map the different methods for diagnostic imaging instruction at medical schools in Brazil.

MATERIALS AND METHODS

In this cross-sectional study, a questionnaire was sent to each of the coordinators of 178 Brazilian medical schools. The following characteristics were assessed: teaching model; total course hours; infrastructure; numbers of students and professionals involved; themes addressed; diagnostic imaging modalities covered; and education policies related to diagnostic imaging.

RESULTS

Of the 178 questionnaires sent, 45 (25.3%) were completed and returned. Of those 45 responses, 17 (37.8%) were from public medical schools, whereas 28 (62.2%) were from private medical schools. Among the 45 medical schools evaluated, the method of diagnostic imaging instruction was modular at 21 (46.7%), classic (independent discipline) at 13 (28.9%), hybrid (classical and modular) at 9 (20.0%), and none of the preceding at 3 (6.7%). Diagnostic imaging is part of the formal curriculum at 36 (80.0%) of the schools, an elective course at 3 (6.7%), and included within another modality at 6 (13.3%). Professors involved in diagnostic imaging teaching are radiologists at 43 (95.5%) of the institutions.

CONCLUSION

The survey showed that medical courses in Brazil tend to offer diagnostic imaging instruction in courses that include other content and at different time points during the course. Radiologists are extensively involved in undergraduate medical education, regardless of the teaching methodology employed at the institution.

Adrenocortical neoplasms in adulthood and childhood: distinct presentation. Review of the clinical, pathological and imaging characteristics

Adrenocortical tumors (ACT) in adulthood and childhood vary in clinical, histopathological, molecular, prognostic, and imaging aspects. ACT are relatively common in adults, as adenomas are often found incidentally on imaging. ACT are rare in children, though they have a significantly higher prevalence in the south and southeast regions of Brazil. In clinical manifestation, adults with ACT present more frequently with glucocorticoid overproduction (Cushing syndrome), mineralocorticoid syndromes (Conn syndrome), or the excess of androgens in women. Subclinical tumors are frequently diagnosed late, associated with compression symptoms of abdominal mass. In children, the usual presentation is the virilizing syndrome or virilizing association and hypercortisolism. Histopathological grading and ACT classification in malignant and benign lesions are different for adults and children. In adults, the described criteria are the Hough, Weiss, modified Weiss, and Van Slooten. These scores are not valid for children; there are other criteria, such as proposed by Wieneke and colleagues. In molecular terms, there is also a difference related to genetic alterations found in these two populations. This review discusses the imaging findings of ACT, aiming to characterize the present differences between ACT found in adults and children. We listed several differences between magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography-computed (PET-CT) and also performed a literature review, which focuses on studied age groups of published articles in the last 10 years regarding cortical neoplasm and imaging techniques. Published studies on ACT imaging in children are rare. It is important to stress that the majority of publications related to the differentiation of malignant and benign tumors are based almost exclusively on studies in adults. A minority of articles, however, studied adults and children together, which may not be appropriate.

Reproducibility and interobserver agreement of the R.E.N.A.L. nephrometry score: focus on imaging features

OBJECTIVE

To investigate the reproducibility and interobserver agreement for R.E.N.A.L. nephrometry scoring system.

MATERIALS AND METHODS

Two independent radiologists retrospectively analyzed 46 consecutive patients with renal masses, between 2008 and 2012, using the R.E.N.A.L. nephrometry score (RENAL-NS), which is based on the evaluation of five anatomical features of the tumor, as evaluated with computed tomography or magnetic resonance imaging: Radius, Exophytic/endophytic properties, Nearness to the collecting system, Anterior or posterior descriptor, and Location relative to the polar line. Tumor complexity was graded as low, intermediate, or high. The interobserver agreement was calculated for the total score and for the score for each parameter. Surgical excision of the tumors was used as the standard of reference.

RESULTS

The interobserver agreement for each of the RENAL-NS parameters, respectively, a hilar location, and the total score was 98%, 80%, 100%, 89%, 85%, 89%, and 93% of patients, corresponding to kappa values of 0.96, 0.65, 1.00, 0.75, 0.72, 0.78, and 0.88, respectively. The Nearness, Radius, and total score showed the best agreement. For the cases that were discordant in terms of the final score, no major implications in surgical planning were observed.

CONCLUSION

The RENAL-NS is a structured, useful system to assess the anatomical features of renal tumors. It is easily applicable and reproducible, even for less experienced radiologists.

Apparent diffusion coefficient of normal adrenal glands

Objective

To assess the feasibility and reliability of apparent diffusion coefficient (ADC) measurements of normal adrenal glands.

Materials and methods

This was a retrospective study involving 32 healthy subjects, divided into two groups: prepubertal (PreP, n = 12), aged from 2 months to 12.5 years (4 males; 8 females); and postpubertal (PostP, n = 20), aged from 11.9 to 61 years (5 males; 15 females). Diffusion-weighted magnetic resonance imaging (DW-MRI) sequences were acquired at a 1.5 T scanner using b values of 0, 20, 500, and 1000 s/mm². Two radiologists evaluated the images. ADC values were measured pixel-by-pixel on DW-MRI scans, and automatic co-registration with the ADC map was obtained.

Results

Mean ADC values for the right adrenal glands were 1.44 × 10^-3 mm²/s for the PreP group and 1.23 × 10^-3 mm²/s for the PostP group, whereas they were 1.58 × 10^-3 mm²/s and 1.32 × 10^-3 mm²/s, respectively, for the left glands. ADC values were higher in the PreP group than in the PostP group (p < 0.05). Agreement between readers was almost perfect (intraclass correlation coefficient, 0.84-0.94; p < 0.05).

Conclusion

Our results demonstrate the feasibility and reliability of performing DW-MRI measurements of normal adrenal glands. They could also support the feasibility of ADC measurements of small structures.

Pelvic symptoms after radiotherapy in prostate cancer: a cross-sectional study

Abstract Introduction: Despite the technical and scientific progress that improved therapeutic resources available in Oncology, adverse effects of treatment can be prominent, impacting the quality of life (QoL). Objective: This research aims to determine the prevalence of post-radiotherapy pelvic symptoms in prostate cancer (PC) and its impact on QoL. Methods: We assessed three groups of patients at different stages during radiotherapy (RT): Pre-RT, evaluated before of RT; Post-RT#1, evaluated between six months and one year post-RT; Post-RT#2, evaluated between two and a half and four years post-RT. The presence of urinary incontinence (UI), its characteristics and impact on daily living activities (DLA) were evaluated by ICIQ-SF questionnaire. WHOQOL-BREF questionnaire was used to assess QoL. Student t test was used, considering significant p < 0.05. Results: Thirty-three men were assessed (pre-RT, n = 12; Post-RT#1, n = 10; Post-RT#2, n = 11). The prevalence of lower urinary tract symptoms (LUTS) was highest in Post-RT#1 group. Post-RT#2 group had the highest prevalence of post-RT UI. In QoL, Pre-RT and Post-RT#2 groups experiencing the greatest impact on physical, environmental and overall QoL. Conclusion: Acute effect of RT is characterized by a high prevalence of LUTS. Post-RT#2 group experienced the most adverse effects on DLA due to a higher prevalence of post-RT UI.

Evaluation of embolization for periuterine varices involving chronic pelvic pain secondary to pelvic congestion syndrome

OBJECTIVES:

To evaluate the clinical response and success rate after periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome and to report the safety of endovascular treatment and its rate of complications.

METHODS:

Retrospective cohort of patients undergoing endovascular treatment of pelvic congestion syndrome in our department from January 2012 to November 2015. Data were analyzed based on patient background, imaging findings, embolized veins, rate of complications, and clinical response as indicated by the visual analog pain scale.

RESULTS:

We performed periuterine varices embolization in 22 patients during the study, four of which required a second embolization. Seventeen patients reported a reduction in pelvic pain after the first embolization and three patients reported a reduction in pelvic pain after the second embolization. Minor complications were observed in our patients, such as postural hypotension, postoperative pain, and venous perforation during the procedure, without clinical repercussion.

CONCLUSION:

Periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome appears to be an effective and safe technique.

Acquired portosystemic collaterals: anatomy and imaging

Portosystemic shunts are enlarged vessels that form collateral pathological pathways between the splanchnic circulation and the systemic circulation. Although their causes are multifactorial, portosystemic shunts all have one mechanism in common-increased portal venous pressure, which diverts the blood flow from the gastrointestinal tract to the systemic circulation. Congenital and acquired collateral pathways have both been described in the literature. The aim of this pictorial essay was to discuss the distinct anatomic and imaging features of portosystemic shunts, as well as to provide a robust method of differentiating between acquired portosystemic shunts and similar pathologies, through the use of illustrations and schematic drawings. Imaging of portosystemic shunts provides subclinical markers of increased portal venous pressure. Therefore, radiologists play a crucial role in the identification of portosystemic shunts. Early detection of portosystemic shunts can allow ample time to perform endovascular shunt operations, which can relieve portal hypertension and prevent acute or chronic complications in at-risk patient populations.

Meta-generalis: A novel method for structuring information from radiology reports

BACKGROUND

A structured report for imaging exams aims at increasing the precision in information retrieval and communication between physicians. However, it is more concise than free text and may limit specialists' descriptions of important findings not covered by pre-defined structures. A computational ontological structure derived from free texts designed by specialists may be a solution for this problem. Therefore, the goal of our study was to develop a methodology for structuring information in radiology reports covering specifications required for the Brazilian Portuguese language, including the terminology to be used.

METHODS

We gathered 1,701 radiological reports of magnetic resonance imaging (MRI) studies of the lumbosacral spine from three different institutions. Techniques of text mining and ontological conceptualization of lexical units extracted were used to structure information. Ten radiologists, specialists in lumbosacral MRI, evaluated the textual superstructure and terminology extracted using an electronic questionnaire.

RESULTS

The established methodology consists of six steps: 1) collection of radiology reports of a specific MRI examination; 2) textual decomposition; 3) normalization of lexical units; 4) identification of textual superstructures; 5) conceptualization of candidate-terms; and 6) evaluation of superstructures and extracted terminology by experts using an electronic questionnaire. Three different textual superstructures were identified, with terminological variations in the names of their textual categories. The number of candidate-terms conceptualized was 4,183, yielding 727 concepts. There were a total of 13,963 relationships between candidate-terms and concepts and 789 relationships among concepts.

CONCLUSIONS

The proposed methodology allowed structuring information in a more intuitive and practical way. Indications of three textual superstructures, extraction of lexicon units and the normalization and ontologically conceptualization were achieved while maintaining references to their respective categories and free text radiology reports.

Addition of n-butyl cyanoacrylate to classic transarterial chemoembolization may improve the radiological response in patients with hepatocellular carcinoma

OBJECTIVE

Transarterial chemoembolization is the treatment of choice for intermediate-stage hepatocellular carcinoma. However, there are no clear data supporting transarterial chemoembolization vs . transarterial embolization or regarding the best chemotherapeutic agent, which may suggest a preponderant role of ischemia over chemotherapeutic action. This study sought to evaluate the radiological response and outcome of transarterial chemoembolization modified by n-butyl cyanoacrylate addition compared to conventional transarterial chemoembolization in hepatocellular carcinoma patients.

MATERIALS AND METHODS

A retrospective review identified forty-seven patients who underwent modified chemoembolization and thirty-three who underwent conventional chemoembolization between June 2006 and December 2011. The radiological response was reassessed using the modified Response Evaluation Criteria in Solid Tumors. The sustained complete response, time to progression and overall survival rates were also analyzed.

RESULTS

Complete response rates were significantly higher in patients who had undergone modified chemoembolization compared to those who had undergone conventional treatment (61.7% and 24.3%, respectively; p < 0.001). The rate of sustained complete response was significantly higher in the modified chemoembolization group compared to the conventional chemoembolization group (median of 236 and 37 days, respectively; p < 0.001). Time to progression was significantly higher in the modified chemoembolization group compared to the conventional chemoembolization group (median of 424 and 201 days, respectively; p = 0.042). Overall survival rates revealed no difference between patients who received modified chemoembolization and conventional chemoembolization (median of 483 and 399 days, respectively; p = 0.316).

CONCLUSION

Transarterial chemoembolization modified by n-butyl cyanoacrylate addition was superior to conventional transarterial chemoembolization in terms of the radiological response in the first imaging control. Although the sustained complete response and time to progression rates were higher for the modified chemoembolization group, no differences in overall survival rates were observed.