Introduction Brushings at ERCP play a crucial role in establishing a diagnosis in cases of biliary strictures. In this study, we examined if brushing practice can make a difference to the diagnostic yield resulting in less interventions. We analysed ERCP data over the last two and a half years at the Royal Berkshire Hospital, where inclusion of the brush head for cytology and performing three or more passages across the stricture has been standard practice. Methods We looked at results of brushings taken by 2 ERCPists in a single centre between September 2016 to February 2018. The initial brushing result from each individual patient was included. Brushing results were classified as non-diagnostic, negative, atypical, suspicious or positive for malignancy. Brushings classified as suspicious and identified as malignant were categorised into the positive group; those classified as non-diagnositc, non-malignant and atypical were categorised as negative. For comparison purposes we considered the corresponding histology and/or radiological findings and/or positive immunohistochemistry in the follow-up period. Data was analysed using the statistical package SPSS v.25. Results In total, 71 individual brushing outcomes were identified over a 2.5-year period. In 61 of 71 cases (85.9%) the final diagnosis was cancer, with the majority being pancreatic cancer (36/61; 59%). The sensitivity was estimated at 77% (47/61 true positive), the specificity and the positive predictive value (PPV) were both 100% (0 false negative, 10 true negative), while the negative predictive value (NPV) was 38%. When we looked at only ‘positive for malignancy’ results, the sensitivity stood at 60%. In 15/61 cases (24.6%) a supplementary report was needed to confirm the result and it changed the outcome in only 3 cases (20%). Conclusions Biliary brushings are a very useful means of providing a diagnosis during ERCP and are characterised by a high PPV and low NPV. Negative results should not be interpreted as absence of malignancy but if the yield is at least suspicious, the specificity approaches 100%. This study suggests that sending the brush head for cytology and performing three or more passages across the stricture increases diagnostic sensitivity when compared to published data reporting on sensitivities up to 64% (Burnett AS, Calvert TJ, Chokshi RJ. Sensitivity of endoscopic retrograde cholangiopancreatography standard cytology: 10-y review of the literature. J Surg Res. 2013;184:304– 11.)

OBJECTIVE. MRI of the prostate is widely used in prostate cancer for local staging. The purpose of this article is to show how preoperative prostate MRI findings may be used as a road map for surgery to preserve the neurovascular bundle, identify risk factors associated with positive surgical margins, and evaluate findings associated with intraoperative complications and functional recovery after surgery. CONCLUSION. Knowledge of surgically relevant imaging findings can increase radiologists' confidence in reporting them to our colleagues.

PURPOSE:We aimed to prospectively evaluate anatomic chest computed tomography (CT) with tissue characterization late gadolinium-enhanced magnetic resonance imaging (MRI) in the evaluation of pulmonary fibrosis (PF).METHODS:Twenty patients with idiopathic pulmonary fibrosis (IPF) and twelve control patients underwent late-enhanced MRI and high-resolution CT. Tissue characterization of PF was depicted using a segmented inversion-recovery turbo low-angle shot MRI sequence. Pulmonary arterial blood pool nulling was achieved by nulling main pulmonary artery signal. Images were read in random order by a blinded reader for presence and extent of overall PF (reticulation and honeycombing) at five anatomic levels. Overall extent of IPF was estimated to the nearest 5% as well as an evaluation of the ratios of IPF made up of reticulation and honeycombing. Overall grade of severity was dependent on the extent of reticulation and honeycombing.RESULTS:No control patient exhibited contrast enhancement on lung late-enhanced MRI. All IPF patients were identified with late-enhanced MRI. Mean signal intensity of the late-enhanced fibrotic lung was 31.8±10.6 vs. 10.5±1.6 for normal lung regions, P < 0.001, resulting in a percent elevation in signal intensity from PF of 204.8%±90.6 compared with the signal intensity of normal lung. The mean contrast-to-noise ratio was 22.8±10.7. Late-enhanced MRI correlated significantly with chest CT for the extent of PF (R=0.78, P = 0.001) but not for reticulation, honeycombing, or coarseness of reticulation or honeycombing.CONCLUSION:Tissue characterization of IPF is possible using inversion recovery sequence thoracic MRI.

Axillary lymph nodes (axLN) are a rare site of nodal metastases in patients with lung cancer. BRAF mutated lung cancer is a genetically distinct subtype that occurs in 2-5% of non-small cell lung carcinomas (NSCLC). A recent study identified a highly unusual pattern of metastatic spread to axLN in patients with BRAF mutated colorectal cancer (CRC). The purpose of the study is to assess the incidence of axLN metastases in BRAF mutated NSCLC. Baseline computed tomography (CT) imaging at diagnosis and all follow up CTs of patients with BRAF mutated NSCLC treated at our institution were retrospectively reviewed by two radiologists for evidence of axLN metastases. Positron emission tomography (PET)/CT was reviewed when available. A control group of patients with non-BRAF mutated NSCLC was assessed. Three criteria were used for the diagnosis of a metastatic node; pathologic confirmation, radiologic size greater ≥1.5cm in short axis diameter or fluorodeoxyglucose avidity on PET/CT and radiologic size ≥1.0cm in short axis diameter. Forty-six patients with BRAF mutated NSCLC and CT images on the institutional PACS were identified. 7 (15%) patients with BRAF mutated NSCLC had axLN metastases using the proposed diagnostic criteria. One patient had a pathologic proven axLN metastasis, 3 had axLNs measuring ≥1.5cm in short axis, and 3 had nodes which were FDG avid on PET/CT and measured ≥1.0cm in short axis. By comparison, 1 of 46 (2%) control patients with non-BRAF mutated NSCLC had axLN metastases. Previous series have reported the prevalence of axLN metastases in patients with NSCLC as 0.61-0.75%. We have found a higher incidence of axLN metastases in BRAF mutated NSCLC patients than described in non-BRAF mutated NSCLC patients. Examination of the axilla should be a routine part of physical examination in this genetically distinct subgroup of lung cancer patients.

Historically, cancer treatment has emphasized measures for the “cure” regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

Treatment with the ALK inhibitor crizotinib has been associated with complex renal cyst formation in patients with non-small cell lung cancer (NSCLC). Using patients treated with crizotinib, we aimed to evaluate the incidence of renal cyst formation, to identify risk factors for cyst formation and to provide a radiological description of cyst characteristics. Patients with ALK-positive NSCLC treated with crizotinib were retrospectively identified from an institutional database. Computed tomography (CT) imaging performed prior to and during crizotinib treatment was retrospectively reviewed to assess the size and complexity of pre-existing cysts, new cysts, and enlarging cysts. Demographic data including age, sex, ethnicity, smoking history and length of treatment were also recorded. Data from 60 patients with NSCLC treated with crizotinib at our institution between 6/5/2009 and 7/1/2015 were collected. 57 had CT imaging before and during treatment. Mean length of imaging follow-up was 18 months. 9 (16%) patients had cysts which enlarged or developed de novo during treatment. 2 (4%) patients developed complex renal cysts (1 of these patients also developed complex hepatic cysts). Female gender (p=0.008) and the presence of renal cysts on baseline scans (p=0.044) were significantly associated with cyst formation or growth. Renal cyst formation or growth occurred in 16% of crizotinib-treated patients. Women and those with pre-existing cysts were at greatest risk. Although the potential causal relationship between crizotinib use and renal cyst formation has yet to be fully defined, it is important for radiologists and clinicians to be aware of this finding.

In the course of writing a recently published appraisal of guidelines relating to cystic pancreatic neoplasms (CPNs) using evidence-based medicine methods [ 1 Cahalane A.M. Purcell Y.M. Lavelle L.P. et al. Which is the best current guideline for the diagnosis and management of cystic pancreatic neoplasms? An appraisal using evidence-based practice methods. Eur Radiol. 2016 Jan 13; ([Epub ahead of print]) Google Scholar ], we conducted a comprehensive search of both the primary and secondary literature to identify all relevant guidelines. This included detailed searches through PubMed [ 2 National Center for Biotechnology Information. PubMed. Available at: http://www.ncbi.nlm.nih.gov/pubmed. Accessed June 9, 2016. Google Scholar ] and numerous online guideline databases. Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings CommitteeJournal of the American College of RadiologyVol. 7Issue 10PreviewAs multidetector CT has come to play a more central role in medical care and as CT image quality has improved, there has been an increase in the frequency of detecting “incidental findings,” defined as findings that are unrelated to the clinical indication for the imaging examination performed. These “incidentalomas,” as they are also called, often confound physicians and patients with how to manage them. Although it is known that most incidental findings are likely benign and often have little or no clinical significance, the inclination to evaluate them is often driven by physician and patient unwillingness to accept uncertainty, even given the rare possibility of an important diagnosis. Full-Text PDF Author’s ReplyJournal of the American College of RadiologyVol. 13Issue 10PreviewWe thank the authors for their positive comments about the white paper on incidental findings published in 2010 and are sorry that we failed to include all of the key words that might have led them to identifying this paper earlier to assist in their research [1]. However, it is unclear why the paper was not originally identified, because “pancreatic cyst” was one of the terms included in our key word list. Although it is not an excuse, one reason for this problem may be that this paper included the discussion of four separate organ systems, which would have required a larger number of search terms. Full-Text PDF

Haemangiomas of the vertebrae, usually regarded as having little or no consequence, may display aggressive features, including extension into the extradural space, and cause significant neurological symptoms and signs necessitating treatment. Extraosseous haemangiomas in an extradural or intradural extramedullary location are a rare entity. Here we review our radiologic and pathologic experience of osseous haemangiomas with extradural extension and primary extradural and intradural extramedullary haemangiomas. Magnetic resonance imaging plays a pivotal role in the characterisation of spinal haemangiomas, with typical imaging features including T1 and T2 signal hyperintensity. Atypical and aggressive imaging features are also described. Spinal angiography may be required to differentiate haemangiomas from non-vascular lesions. This is a rare and unusual entity, and should be considered as a differential diagnosis for some extramedullary masses.

BACKGROUND AND AIM:Cystic pancreatic neoplasms (CPNs) are an increasingly diagnosed entity. Their heterogeneity poses complex diagnostic and management challenges. Despite frequently encountering these entities, particularly in the context of the increased imaging of patients in modern medicine, doctors have to rely on incomplete and ambiguous published literature. The aim of this project was to review the guidelines relating to CPNs using evidence-based practice (EBP) methods.METHODS:A search of both the primary and secondary literature was performed. Five sets of guidelines were identified which were then methodologically appraised by the AGREE II instrument, a validated and widely utilised tool for guideline development assessment.RESULTS:The 2014 'Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms' were found to be the most methodologically sound guidelines, on the basis of both the overall score and average weighted domain score.CONCLUSIONS:The current best guidelines were identified. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument can be used for retrospective review of published guidelines or as a roadmap for guideline-writing groups. All guidelines found were methodologically limited. Further longitudinal/prospective studies are required to improve the level of evidence.KEY POINTS:• Cystic pancreatic neoplasms (CPNs) are an increasingly encountered entity in modern medicine. • Clinical uncertainty remains with regard to optimal diagnostic and management strategies. • The Italian consensus guidelines for cystic pancreatic neoplasms are currently the best guidelines.

BACKGROUND:To evaluate the relationship between lung parenchymal abnormalities on chest CT and health-related quality of life in adult cystic fibrosis (CF).METHODS:The chest CT scans of 101 consecutive CF adults (mean age 27.8±7.9, 64 males) were prospectively scored by two blinded radiologists in consensus using a modified Bhalla score. Health-related quality of life was assessed using the revised Quittner Cystic Fibrosis Questionnaire (CFQ-R). Multiple regressions were performed with each of the CFQ-R domains and all clinical and imaging findings to assess independent correlations.RESULTS:There were 18 inpatients and 83 outpatients. For the cohort of inpatients, CT abnormalities were significantly (P<0.005 for all) associated with Respiratory Symptoms (Air Trapping), and also with Social Functioning (Consolidation) and Role Functioning (Consolidation). For outpatients, CT abnormalities were significantly (P<0.005 for all) associated with Respiratory Symptoms (Consolidation) and also with Physical Functioning (Consolidation), Vitality (Consolidation, Severity of Bronchiectasis), Eating Problems (airway wall thickening), Treatment Burden (Total CT Score), Body Image (Severity of Bronchiectasis) and Role Functioning (Tree-in-bud nodules). Consolidation was the commonest independent CT predictor for both inpatients (predictor for 2 domains) and outpatients (predictor in 3 domains). Several chest CT abnormalities excluded traditional measures such as FEV1 and BMI from the majority of CFQ-R domains.CONCLUSIONS:Chest CT abnormalities are significantly associated with quality of life measures in adult CF, independent of clinical or spirometric measurements.

AimsTo determine whether specific magnetic resonance enterography (MRE) findings can predict outcome following commencement of antitumor necrosis factor (aTNF) in small bowel Crohn's disease (CD)Patients and methodsThis was a single-centre retrospective study of patients with CD who commenced aTNF (infliximab or adalimumab) between 2007 and 2013. Patients who had an MRE within 6 months before commencing aTNF were included. The primary end-point was the need for CD-related surgery. The secondary end-points were time to surgery and time to treatment failure. The relationship between these end-points, clinical variables and specific MRE findings were studied.ResultsFour hundred and eighteen patients commenced aTNF for CD during the study period. Seventy-five patients had an MRE within 6 months before commencing aTNF (30 infliximab; 45 adalimumab). The median time from MRE to commencing aTNF was 43 days (IQR 19.5-87 days). Eighteen of 75 (24%) had surgery during a median follow-up of 16.7 months (IQR 9.0-30.1 months). Patients with small bowel stenosis (SBS) on MRE were at a significantly higher risk of requiring surgery: 12/18 (66.7%) versus 6/57 (10.5%) (P<0.001). Time to surgery was significantly shorter in patients with SBS on MRE (P<0.001). In a multivariate analysis, SBS (P<0.0001, hazard ratio 26.45, 95% confidence interval 5.45-128.49) and presence of penetrating complications (P=0.003, hazard ratio 36.53, 95% confidence interval 3.40-393.19) were associated independently with time to surgery.ConclusionSBS and penetrating complications on MRE are associated independently with a need for early surgery and treatment failure in patients commencing aTNF. Copyright (C) 2015 Wolters Kluwer Health, Inc. All rights reserved.

Introduction: Acute mesenteric ischaemia (AMI) continues to have a high mortality, ranging from 60 to 80%.Presentation of case: A 78-year-old male presented with a 20-hour history of abdominal pain, secondary to a superior mesenteric artery (SMA) thromboembolic occlusion diagnosed on computed tomography (CT) angiography. Following confirmation of bowel viability at laparotomy, endovascular intervention using combined thrombolysis, angioplasty and thromboaspiration was performed. Despite successful recanalisation of the occlusion, his condition continued to deteriorate fatally due to progressive sepsis.Discussion: We discuss the role of biphasic CT in diagnosis of AMI, and review the evidence for endovascular interventions now increasingly used in the emergent management of thromboembolic AMI.Conclusion: Early diagnosis using CT angiography is essential, as it is highly sensitive in detecting a visceral arterial occlusion. However, laparotomy is often required to accurately determine bowel viability and the need for resection. Endovascular interventions appear to be effective alternatives to open surgery with appropriate patient selection. (C) 2014 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

OBJECTIVES:Prostate cancer staging MR examinations commonly include abdominal sequences to assess for non-regional (common iliac or para-aortic) nodal metastasis. In our experience the diagnostic yield of this is limited, but incidental findings are frequent, often necessitating further investigations. The aim of this study is to assess the diagnostic utility of abdominal sequences in routine prostate cancer MR staging studies. METHODS:Findings on abdominal sequences of consecutive MRI prostate studies performed for staging newly diagnosed prostate cancer between September 2011 and September 2013 were reviewed with respect to adenopathy and additional incidental findings. Results were correlated with Gleason grade and serum prostate-specific antigen (PSA) level in each case. RESULTS:355 MRI prostate examinations were reviewed. 4 (1.1%) showed enlarged non-regional lymph nodes. Incidental findings were found in 82(23.1%) cases, neccessitating further investigation in 45 (12.7%) cases. Enlarged non-regional nodes were associated with higher PSA level and Gleason grade (p=0.007, p=0.005 respectively). With a combined threshold of PSA > 20 ng/mL and/or Gleason grade ≥ 8 the sensitivity, specificity, PPV and NPV were 100, 60, 3 and 100% respectively for predicting the presence of non-regional adenopathy. CONCLUSIONS:Routine abdominal sequences are of very low yield in routine prostate cancer MR staging, frequently resulting in incidental findings requiring further work-up and should be reserved for high-risk cases. Our experience supports the use of an abdominal staging sequence in high-risk cases only.

Hyperacute stroke imaging is playing an increasingly important role in determining management decisions in acute stroke patients, particularly patients with large vessel occlusive stroke who may benefit from endovascular intervention. CT angiography (CTA) is an important tool in the work-up of the acute stroke patient. It reliably detects large occlusive thrombi in proximal cerebral arteries and is a quick and highly accurate method in identifying candidates for endovascular stroke treatment. In this article we review the imaging findings on CTA in acute large vessel occlusive stroke using a pictorial case based approach. We retrospectively reviewed CTA studies in 48 patients presenting with acute anterior circulation large vessel occlusive stroke who were brought for intra-arterial acute stroke intervention. We discuss and illustrate patterns of proximal intracranial arterial occlusion, collateralization to the occluded territory, as well as reviewing some important pearls, pitfalls and teaching points in CTA assessment of the acute stroke patient. Performed from the level of the aortic arch CTA also gives valuable information regarding the state of other vessels in the acute stroke patient, identifying additional significant vascular stenoses or occlusions, and as we illustrate, can demonstrate other clinically significant findings which may impact on patient management and outcome.

Magnetic resonance enterography (MRE) has a growing role in imaging small bowel Crohn's disease (SBCD), both in diagnosis and assessment of treatment response. Certain SBCD phenotypes respond well to biologic therapy and others require surgery; MRE has an expanding role in triaging these patients. In this review, we evaluate the MRE signs that subclassify SBCD using evidence-based medicine (EBM) methodology and provide a structured approach to MRE interpretation. (C) 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Accurate imaging detection and quantification of fibrotic pulmonary sarcoid is important for diagnosis, treatment and prognosis. 1–3 The gold-standard non-invasive imaging test remains high resolution chest computed tomography (HRCT), which is now widely utilized worldwide in the diagnosis and follow-up of sarcoid, has been used extensively in numerous clinical drug trials and is an outcome measure in sarcoid. 4–7 However, it typically relies on the anatomical depiction of fibrosis, characterized by traction bronchiectasis, reticulation and honeycombing.8,9 A major limitation of this approach relates to anatomical mimics such as emphysema and chronic pneumoconiosis, which can have similar imaging appearances.6 Imaging modalities such as magnetic resonance imaging (MRI) have also been used extensively in the investigation of fibrotic pulmonary sarcoid with varying degrees of success.10–16 The advantages of MRI are its lack of ionizing radiation and versatile tissue characterization abilities, whilst its limitations relate principally to spatial resolution and contrast-to-noise ratios in depicting the lung parenchyma compared to HRCT. Although several non-contrast and contrast enhanced MRI protocols have been published to assess pulmonary fibrosis, none have acquired widespread acceptance in routine clinical practice.17 Contrast late-enhanced cardiac MRI has been utilized in cardiac imaging to detect, localize and quantify myocardial fibrosis.18,19 Many studies have shown that a specific double-inversion recovery sequence acquired ∼10 min after intravenous contrast administration demonstrates contrast wash out of normal myocardium and late enhancement of myocardial fibrosis, the increased gadolinium concentration within myocardial fibrosis corresponding to the increased extracellular space characteristic of fibrotic tissue.20 Since gadolinium is an extracellular contrast agent, it diffuses out of the blood pool and normal tissues and concentrates in tissues with an enlarged extracellular space. Such late enhancement can be exploited to detect myocardial fibrosis in many cardiomyopathies.18,21 We hypothesized that since …

Cystic fibrosis (CF) is the most common lethal autosomal recessive disease in the white population. Mutation of the CF transmembrane conductance regulator gene on chromosome 7 results in production of abnormally viscous mucus and secretions in the lungs of patients with CF. A similar pathologic process occurs in the gastrointestinal tract, pancreas, and hepatobiliary system. Inspissated mucus causes luminal obstruction and resultant clinical and radiologic complications associated with the disease process. Pancreatic involvement can result in exocrine and endocrine insufficiency, pancreatic atrophy, fatty replacement, or lipomatous pseudohypertrophy. Acute and chronic pancreatitis, pancreatic calcification, cysts, and cystosis also occur. Hepatic manifestations include hepatic steatosis, focal biliary and multilobular cirrhosis, and portal hypertension. Biliary complications include cholelithiasis, microgallbladder, and sclerosing cholangitis. The entire digestive tract can be involved. Distal ileal obstruction syndrome, intussusception, appendicitis, chronic constipation, colonic wall thickening, fibrosing colonopathy, pneumatosis intestinalis, gastroesophageal reflux, and peptic ulcer disease have been described. Renal manifestations include nephrolithiasis and secondary amyloidosis. The educational objectives of this review are to reveal the abdominal manifestations of CF to facilitate focused analysis of cross-sectional imaging in adult patients. Life expectancy in patients with CF continues to improve because of a combination of aggressive antibiotic treatment, improved emphasis on nutrition and physiotherapy, and development of promising new CF transmembrane conductance regulator modulators. As lung function and survival improve, extrapulmonary conditions, including hepatic and gastrointestinal malignancy, will be an increasing cause of morbidity and mortality. Awareness of the expected abdominal manifestations of CF may assist radiologists in identifying acute inflammatory or neoplastic conditions. (©)RSNA, 2015.

Pancreaticopleural fistula is a rare clinical entity. The classical presentation is that of a left sided, amylase-rich pleural effusion [1,2] . Herein we report an unusual case of pancreatic ductal adenocarcinoma that presented initially with a pancreaticopleural fistula. We review and discuss the existing literature regarding pancreaticopleural fistulae that are associated with a pancreatic neoplasm.