Benign and malignant mimickers of infiltrative hepatocellular carcinoma: tips and tricks for differential diagnosis on CT and MRI

Hepatocellular carcinoma (HCC) may have an infiltrative appearance in about 8–20% of cases. Infiltrative HCC can be a challenging diagnosis and it is associated with the worst overall survival among HCC patients. Infiltrative HCC is characterized by the spread of multiple minute nodules throughout the liver, without a dominant one, ultimately resulting into macrovascular invasion. On CT and MRI, infiltrative HCC appears as an ill-defined, large mass, with variable degree of enhancement, and satellite neoplastic nodules in up to 52% of patients. On MRI, it may show restriction on diffusion weighted imaging, hyperintensity on T2- and hypointensity on T1-weighted images, and, if hepatobiliary agent is used, hypointensity on hepatobiliary phase. Infiltrative HCC must be differentiated from other liver diseases, such as focal confluent fibrosis, steatosis, amyloidosis, vascular disorders of the liver, cholangiocarcinoma, and diffuse metastatic disease. In cirrhotic patients, the identification of vascular tumor invasion of the portal vein and its differentiation from bland thrombosis is of utmost importance for patient management. On contrast enhanced CT and MRI, portal vein tumor thrombosis appears as an enhancing thrombus within the portal vein, close to the main tumor and results into vein enlargement. The aim of this pictorial review is to show CT and MRI features that allow the diagnosis of infiltrative HCC and portal vein tumor thrombosis. A particular point of interest includes the tips and tricks for differential diagnosis with potential mimickers of infiltrative HCC

MR Imaging of Perianal Crohn Disease: The Role of Contrast-enhanced Sequences

The MR imaging protocol described by the authors includes contrast-enhanced T1-weighted imaging with fat saturation in all patients except those with poor renal function. Horsthuis et al demonstrated in 2009 the usefulness of contrast-enhanced MR imaging for determining disease activity. Contrast agent administration is also required in case of suspicion of neoplastic tissue complicating fistulas. The joint European Crohn\u2019s and Colitis Organisation\u2013European Society of Gastointestinal and Abdominal Radiology guidelines report that T2-weighted images and contrast-enhanced T1-weighted images are included in the MR imaging protocol for the evaluation of perianal CD. However, as we have demonstrated, an axial T2-weighted fast spinecho sequence with fat saturation, in particular the short inversion time inversion-recovery (STIR) sequence, is a valid alternative to postcontrast T1- weighted fat-saturated imaging, allowing the identification of the primary fistula and any secondary ramification

Resectable and borderline resectable pancreatic ductal adenocarcinoma: Role of the radiologist and oncologist in the era of precision medicine

The incidence and mortality of pancreatic ductal adenocarcinoma are growing over time. The management of patients with pancreatic ductal adenocarcinoma involves a multidisciplinary team, ideally involving experts from surgery, diagnostic imaging, interventional endoscopy, medical oncology, radiation oncology, pathology, geriatric medicine, and palliative care. An adequate staging of pancreatic ductal adenocarcinoma and re-assessment of the tumor after neoadjuvant therapy allows the multidisciplinary team to choose the most appropriate treatment for the patient. This review article discusses advancement in the molecular basis of pancreatic ductal adenocarcinoma, diagnostic tools available for staging and tumor response assessment, and management of resectable or borderline resectable pancreatic cancer

ETHICS AND AGING: FOCUS ON LIVING WILL FOR PATIENTS WITH DEMENTIA

Today dementia certainly represents a public health priority with a huge global impact on wordwide population. However, clinical and social issues related to demen-tia have long been marginalized. The actual high prevalence of dementias requires also to face issues from a bioethical perspective, regarding how to deal with demented patient\u2019s disposition. There are currently no specific guide-lines on the national territory regarding whether to draw up a living will by a patient with dementia, neither about the informa-tive role of physicians during the progres-sive story of the disease

Small Bowel Perforations: What the Radiologist Needs to Know

The incidence of small bowel perforation is low but can develop from a variety of causes including Crohn disease, ischemic or bacterial enteritis, diverticulitis, bowel obstruction, volvulus, intussusception, trauma, and ingested foreign bodies. In contrast to gastroduodenal perforation, the amount of extraluminal air in small bowel perforation is small or absent in most cases. This article will illustrate the main aspects of small bowel perforation, focusing on anatomical reasons of radiological findings and in the evaluation of the site of perforation using plain film, ultrasound, and multidetector computed tomography equipments. In particular, the authors highlight the anatomic key notes and the different direct and indirect imaging signs of small bowel perforation

The Benign Side of the Abdominal Wall: A Pictorial Review of Non-Neoplastic Diseases

The abdominal wall is the location of a wide spectrum of pathological conditions, from benign to malignant ones. Imaging is often recommended for the evaluation of known palpable abdominal masses. However, abdominal wall pathologies are often incidentally discovered and represent a clinical and diagnostic challenge. Knowledge of the possible etiologies and complications, combined with clinical history and laboratory findings, is crucial for the correct management of these conditions. Specific imaging clues can help the radiologist narrow the differential diagnosis and distinguish between malignant and benign processes. In this pictorial review, we will focus on the non-neoplastic benign masses and processes that can be encountered on the abdominal wall on cross-sectional imaging, with a particular focus on their management. Distinctive sonographic imaging clues, compared with computed tomography (CT) and magnetic resonance (MR) findings will be highlighted, together with clinical and practical tips for reaching the diagnosis and guiding patient management, to provide a complete diagnostic guide for the radiologist

Cardiorenal syndrome: the role of new biochemical markers

Cardiorenal syndrome is a pathophysiological heart and kidney disorder, in which acute or chronic dysfunction of one organ induces a damage in the other. It's a syndrome more and more often encountered in clinical practice and this implies the need to recognize the syndrome through biochemical markers with a good sensitivity and specificity, since its earliest stages in order to optimize therapy. In addition to widely validated biomarkers, such as BNP, pro BNP, creatinine, GFR and cystatin C, other promising molecules are available, like NGAL (neutrophil gelatinase-associated lipocalin, KIM-1 (kidney injury molecule-1), MCP-1 (monocyte chemotactic peptide), Netrin-1, interleuchin 18 and NAG (N-acetyl-β-glucosa-minidase). The role of these emerging biomarkers is still not completely clarified: hence the need of new clinical trials

The Neoplastic Side of the Abdominal Wall: A Comprehensive Pictorial Essay of Benign and Malignant Neoplasms

Abdominal wall neoplasms are usually benign and, in the majority of these cases, no further work-up or treatment is indicated. The percentage of malignant abdominal neoplasms, however, is not negligible. Radiologists play a pivotal role in identifying imaging features that should favor malignancy, including larger lesion size, edema, neurovascular involvement, and peripheral or inhomogeneous dynamic enhancement, thus indicating to the clinician the need for further work-up. Histopathology is the reference standard for the characterization of abdominal wall neoplasms. In patients undergoing surgery, radiological assessment is needed to guide the surgeon by providing a comprehensive anatomic guide of the tumor extension. We present a pictorial review of benign and malignant abdominal wall neoplasms that can be encountered on radiological examinations, with a main focus on CT and MRI features that help in narrowing the differential diagnosis

Surgical complications after pancreatic transplantation: A computed tomography imaging pictorial review

pancreatic transplantation should start with the evaluation of the arterial Y-graft, the venous anastomosis and the duodenojejunostomy. With regard to complications, CT allows for the identification of vascular complications, such as thrombosis or stenosis of blood vessels supplying the graft, the detection of pancreatic fluid collections, including pseudocysts, abscesses, or leaks, the assessment of bowel complications (anastomotic leaks, ileus or obstruction), and the identification of bleeding. The aim of this pictorial review is to illustrate CT findings of surgical-related complications after pancreatic transplantation. The knowledge of surgical techniques is of key importance to understand postoperative anatomic changes and imaging evaluation. Therefore, we first provide a short summary of the main techniques of pancreatic transplantation. Then, we provide a practical imaging approach to pancreatic transplantation and its complications providing tips and tricks for the prompt imaging diagnosis on CT.Pancreatic transplantation is considered by the American Diabetes Association and the European Association for the Study of Diabetes an acceptable surgical procedure in patients with type 1 diabetes also undergoing kidney transplantation in pre-final or end-stage renal disease if no contraindications are present. Pancreatic transplantation, however, is a complex surgical procedure and may lead to a range of postoperative complications that can significantly impact graft function and patient outcomes. Postoperative computed tomography (CT) is often adopted to evaluate perfusion of the transplanted pancreas, identify complications and as a guide for interventional radiology procedures. CT assessment afte

Spectrum of liver lesions hyperintense on hepatobiliary phase: an approach by clinical setting

Hepatobiliary MRI contrast agents are increasingly being used for liver imaging. In clinical practice, most focal liver lesions do not uptake hepatobiliary contrast agents. Less commonly, hepatic lesions may show variable signal characteristics on hepatobiliary phase. This pictorial essay reviews a broad spectrum of benign and malignant focal hepatic observations that may show hyperintensity on hepatobiliary phase in various clinical settings. In non-cirrhotic patients, focal hepatic observations that show hyperintensity in the hepatobiliary phase are usually benign and typically include focal nodular hyperplasia. In patients with primary or secondary vascular disorders, focal nodular hyperplasia-like lesions arise as a local hyperplastic response to vascular alterations and tend to be iso- or hyperintense in the hepatobiliary phase. In oncologic patients, metastases and cholangiocarcinoma are hypointense lesions in the hepatobiliary phase; however, occasionally they may show a diffuse, central and inhomogeneous hepatobiliary paradoxical uptake with peripheral rim hypointensity. Post-chemotherapy focal nodular hyperplasia-like lesions may be tricky, and their typical hyperintense rim in the hepatobiliary phase is very helpful for the differential diagnosis with metastases. In cirrhotic patients, hepatocellular carcinoma may occasionally appear hyperintense on hepatobiliary phase