CTL MRI Pathology CT PATHOLOGY 1- Neck;Nasopharyngeal carcinoma © Clinical triad > Asymptomatic mass due to LNst. Hearing loss due to otitis media. Bloody nasal discharge. > Before age 50 ys & M:F > Relationship é Epstein — Barr virus. > Staging: TI Tumor confined to nasopharynx tissue of oropharynx and/or nasal fossa(Axial) T2 T2a Without parapharyngeal extension* T2b With parapharyngeal extension* 73 Tumor invades bony structures and/or paranasal sinuses Tumor with intracranial extension and/or involvement of cranial 14 nerves, infratemporal fossa, hypopharynx, or orbit. DR, Khaled M, Altaher MDCTL MRI Pathology Regional Regional Lymph Nodes (N) NX Regional nodes cannot be assessed No No regional lymph node metastasis NI Unilateral node(s): 6 cm or less in greatest dimension above supraclavicular fossa ND Bilateral node(s): 6 cm or less in greatest dimension, above supraclavicular fo: N3 Metastasis in lymph node(s): N3a Greater than 6 cm in dimension N3b Tn the supraclavicular fossa Distant Metastasis (M) MO No distant metastases MI Distant metastases are present *Parapharyngeal extension denotes posterolateral infiltration of tumor beyond the pharyngobasilar fascia. ° CT finding: > A soft tissue mass in the lateral wall of the nasopharnx. enhancing mass in the Lateral wall of the nasopharynx extended ant. To nasal fossa through posterior nares Maxillary sinus or infra temporal fossa fat, ptyregoid fossa with destruction of pterygoid posterior to prevertebral muscles, carotid sheath, skull base bones lateral to parapharyngeal space and masticator space. Medially cross the midline affect the contralateral aspect of the nasopharynx, nasopharyngeal air space, retropharyngeal to contralateral side, inferiorly oropharynx or tongue & Superiorly skull base destruction, intracranial extension DR, Khaled M. Altaher MDCTL MRI Pathology 2- Mediastinum; Esophageal varices © Esophageal varices are dilated tortuous submucosal venous plexus of esophagus & are important because of the potentially catastrophic consequences of variceal rupture and hemorrhage. Varices may be classified as uphill or downhill; the Uphill is more common than the downhill. Uphill varices develop by portal hypertension while Downhill varices develop by obstruction of the superior vena cava and result in reversal of flow into the cervical and upper thoracic esophagus. © On CT esophageal varices are recognized by the presence of a dilated vessel on the inner surface of the esophageal wall that is markedly enhanced after administration of IV contrast medium. CT is superior to barium esophagography in evaluating the presence and extent of periesophageal varices and portal hypertension, although the sensitivities in detection of the lesion are similar. Recently MDCT virtual endoscopy technique has been applied to the evaluation of esophageal varices. using air insufflation via a catheter al DR, Khaled M. Altaher MDCTL MRI Pathology +> If appear: It means pathological & Si esophagography can allow accurate grading of esophageal varices with better patient acceptance than endoscopy. CT may play a role in selecting patients with high-risk varices who are potential candidates for preventive treatment. On CT scans, therapeutically sclerosed esophageal varices may sometimes mimic esophageal carcinoma, also a mediastinal effusion of predominantly low attenuation that is often masslike is seen with obliteration of mediastinal fat planes; thickening of the diaphragmatic crura; pleural effusions; and subsegmental atelectasis. Mediastinal lymphadenopathy Mediastinal LNS Normally: No LNS appear in the chest. enlarged LNS es: Retrosternal: Posterior to sternum. Retrocaval: Posterior to SVC . Prevascular: Before the arch of aorta. Aortic window: Is the space between the ascending & oS descending aorta before the appearance of pulmonary artery. Carinal: At the division of the trachea " anterior & posterior " to it. . Subcarinal: In the space in between the bronchi when being away from each other. Hilar. DR, Khaled M, Altaher MDCTL MRI Pathology * Zygo-esophageal: Between the esophagus & hemi-azygos vein which at the RT from the esophagus. * Circum-cardiac LNS: Soft tissue mass around the heart (+ & pericardial effusion) diagnostic of NHL. © Only the retro-caval LN enlargment if single in a patient not complaining from anything , not important but if in any patient complaining from breast cancer , lyphoma , ... it is significant . Aortic aneurysm & dissection (Left) Composite image shows axial NECT (left) and CECT (right) of 2 patients with ruptured aortic aneurysms. Signs of rupture include crescent sign Fd, hemothorax E&, and mediastinal hematoma EE. (Right) Composite image with axial (left) and sagittal CTA (right) of, 2 patient with mycotic aortic aneurysrns secondary to S. aureus aortic valve ndocarditis shows saccular aneurysms near the aortic isthmus. Infectious or ‘mycotic aneurysms are typically secondary to S, aureus and Salmonella spp. DR, Khaled M. Altaher MDCTL MRI Pathology © Definitions; Aortic dilatation > 50% of normal diameter © NECT; Curvilinear mural calcification: Common in atherosclerotic, absent in mycotic aneurysms Crescent sign: Crescentic mural high attenuation indicates contained/impending rupture Hematoma: Hemothorax, hemopericardium, hemomediastinum © CTA; > Blunting of sinotubular junction (annuloaortic ectasia) Crescent-shaped intraluminal thrombus > Intimomedial flap (dissection) (Left) Composite image with axial CTA of 2 patients with type A = pc ft) and type 8 (right) aortic dissection shows the beak sign > Rupture: Active |, an acute angle between the flap and the false lumen. (Right) Composite image with axial CTA of 2 patients with extravasation (uncommon). type A (left) and type B (right) aortic dissections shows the cobweb sign —*, manifesting with subtle linear filling defects representing strands of media in the false lumen. Both signs are important for differentiating the true lumen from the false. juperior vena cava obsruction © SVC obstruction by intraluminal, intramural, or extrinsic disease Impaired venous return from head, neck, upper extremities, & trunk to right atrium Imaging * CT; Non-opacification of SVC > Extrinsic compression by mass or lymphadenopathy rai] DR, Khaled M. Altaher MDCTL MRI Pathology > Intraluminal filling defect > Multiple collateral. * Clinical Issues > Face, neck, upper trunk, & upper extremity edema * Diagnostic Checklist > Consider SVC (Left) Graphic illustrates superior vena cava (SVC) obstruction secondary to mediastinal invasion bya lung tumor with resultant obstruction when brachiocephalic vein > and right intercostal collateral vessel uetion [Pdistention. (Right) Axial CECT shows SVC obstruction by small cell patient with known !ung cancer MaZinvading the mediastinum and multiple distended mediastinal collateral vessels 8. Lung cancer is the most common malignancy develops _©24Se of malignant SVC obstruction, and small cel carcinoma is the most frequent cell type. typical signs & symptoms. (Left) Composite image with PA chest radiograph (left) and axial CECT (right) of a patient with metastatic lung cancer manifesting with a right paratracheal mass Eithat occludes the SVC Edand posterior chest wall collateral vessels E83. (Right) Coronal CECT shows an SVC stent without apparent opacification of the stent lumen S&Jalthough the SVC caudal to the stent is patent E2. Vascular stents may be used to treat SVC obstruction from benign and malignant etiologies. ca DR, Khaled M. Altaher MDCTL MRI Pathology Bronchioalveolar cell carcinoma * (BAC) refers to a spectrum of well-differentiated adenocarcinoma that demonstrates lepidic growth. The hallmark of lepidic growth is a spreading of malignant cells using the alveolar walls as a scaffold. > The opposite of lepidic growth is hilic growth, demonstrated by most other forms of lung cancer, which describes cancer growth by invasion and destruction of lung parenchyma. > A spectrum of lesions have been called BAC ranging from small peripheral tumors with 100% survival to lesions causing widespread advanced disease. Despite this variability, BAC is most commonly indolent and is often negative on PET. > To create more uniformity in the pathological, clinical, and research domains, a new classification for the spectrum of the adenocarcinoma subtypes formerly called BAC has recently been proposed. This classification is primarily based on the pathology of the lesion and differentiation of these Nonmucinous BAC oe a - — (multifocal): Axial CT shows entities on imaging is difficult. In clinical radiologic a solid nodule with air bronchograms (yellow arrow) and a more referred to as BAC. This textbook will continue the peripheral ground glass nodule (red arrow) practice, this spectrum of lesions is routinely still common practice and refer to these lesions as BAC. ka] DR, Khaled M. Altaher MDCTL MRI Pathology > Nonmucinous BAC (adenocarcinoma, predominantly invasive with some nonmucinous lepidic component) classically presents as a ground glass or solid nodule with air bronchograms and has a better prognosis compared to the mucinous subtype. > Mucinous BAC (invasive mucinous adenocarcinoma) tends to present with chronic consolidation. It has a worse prognosis compared with non-mucinous BAC. v Mucinous BAC is an important differential consideration for chronic ground glass or ‘ Mucinous BAC: Axial contrast- enhanced CT shows a right lower lobe consolidative opacity with air bronchograms (arrow) consolidation, often with air bronchograms. v The CT angiogram sign describes the especially prominent appearance of enhancing pulmonary vessels seen in a low attenuation, mucin-rich consolidation of mucinous BAC. 3- Pericardium; Pericardial effusion © The pericardium consists of two layers (the visceral and parietal pericardium), which are separated by approximately 40 mL of pericardial fluid. > The visceral pericardium is too thin to be visualized on imaging. The pericardial apparatus (combination of the visceral and parietal layers and pericardial fluid) measures <1 mm on cadaveric studies and can be seen on CT and MRI, with a normal DR, Khaled M. Altaher MDCTL MRI Pathology thickness <2 mm. A pericardial thickness of >4 mm on imaging is considered clearly abnormal. The primary clinical concern of a pericardial effusion is cardiac tamponade. As little as 100-200 mL of pericardial fluid can impede diastolic filling if it accumulates quickly. cr Water attenuation fluid: Uncomplicated effusion High-attenuation fluid: Hemorrhage, purulent fluid, malignancy Associated pericardial thickening & calcification. Cardiac chambers: Constriction & tamponade. 4- GIT; Gastric diverticulum This is a true diverticulum (Pouch/sac includes 3 normal layers of bowel wall: Mucosa, submucosa, and muscularis propria) — thus it will demonstrate peristalsis, it is usually several cm in size and readily fills with barium, It is most commonly seen within the posterior aspect of the fundus (near the lesser curvature). These are due to invagination of the gastric mucosa into the gastric wall, usually <1cm in size with a lenticular shape (in profile) and a small opening into the gastric lumen, usually occur along the greater curvature. 7 DR, Khaled M. Altaher MDCTL MRI Pathology v v They can be mistaken for an ulcer or pancreatic rest & usually asymptomatic. Most are juxtacardiac diverticula, on posterior aspect of lesser curvature of stomach, usually 1-3 cm, up to 10 cm in diameter CT findings (supine and prone position with oral contrast and gas granules) Often in suprarenal location, mimics adrenal or pancreatic mass Connection to stomach may be subtle Air-filled, fluid-filled, or contrast-filled mass No enhancement of contents Complications (rare); Bleeding, Ulceration, Carcinoma. Colonic adenocarcinoma Definitions Malignant transformation of colonic mucosa Best diagnostic clue Short segment luminal wall thickening Location Sigmoid colon, rectum, ascending colon, transverse colon, Cecum, rectosigmoid colon and descending colon. 7 DR, Khaled M. Altaher MDCTL MRI Pathology * Morphology v Early cancer: Sessile or pedunculated polyps v ‘Advanced cancer: Annular, semiannular, polypoid, or carpet tumors © Other general features > Radiology is critical for screening, diagnosis, treatment, and follow-up of CRC > Screening: Fluoroscopic-guided double-contrast barium enema and CT "virtual colonoscopy" are comparable to colonoscopy for cancer detection by experienced observers * CT Findings > Asymmetric mural thickening of soft tissue density + irregular surface > Tumor limited to lumen: Smooth serosal surface > Extracolonic tumor extension = Mass with irregular serosal surface with stranding of pericolonic fat * Loss of tissue fat planes between colon and surrounding muscles > Metastases to mesenteric nodes, peritoneum. > Hepatic metastases are most common (via portal venous drainage). DR, Khaled M. Altaher MDCTL MRI Pathology Appendicitis Appendicitis: is the most common surgical cause of acute abdomen. Acute inflammation of the appendix is thought to be due to obstruction of the appendiceal lumen, leading to venous congestion, mural ischemia, and bacterial translocation. Appendicitis represents a spectrum of severity ranging from tip appendicitis (inflammation isolated to the distal appendix) to gangrenous appendicitis with abscess if the disease is not diagnosed until late. Greater than 97% of patients undergo a preoperative CT prior to appendectomy, with resultant decrease in negative appendectomy rate from 23% in 1990 to 1.7% in 2007. Imaging of appendicitis relies on direct and indirect Coronal and axial CECT shows imaging findings. a large focus of inflammatory stranding centered around the Direct findings of appendicitis are due to abnormalities pPendix in the right lower quadrant (yellow arrows). The of the appendix itself: margins of the appendix itself are indistinct and there is the Distended, fluid-filled appendix: 6 mm is used as cutoff Suggestion of an early fluid collection (blue arrows). Note for normal diameter of the appendix, although there is the two appendicoliths within the appendix (red arrows) wide normal variability and a normal appendix distended with air can measure >6 mm. ch DR, Khaled M. Altaher MDCTL MRI Pathology > Appendiceal wall-thickening, > Appendicolith, which may be a cause of luminal obstruction; however, appendicoliths are commonly seen without associated appendicitis. * Indirect findings of appendicitis are due to the spread of inflammation to adjacent sites: Periappendiceal fat stranding, Cecal wall thickening, Hydroureter & Small bowel ileus. 5- Lungs; Lung collapse © On imaging studies, loss of volume (atelectasis) is one of the most common CT _ abnormalities encountered. The various imaging manifestations of atelectasis; range from subsegmental atelectasis (often seen in hospitalized and bedridden patients) to the various patterns of lobar atelectasis that may herald the presence of an underlying obstructive tumor. Mechanisms The atelectasis may be obstructive or nonobstructive in nature, and each mechanism may operate independently or in combination with the others. Obstructive atelectasis occurs most commonly and involves resorption of air that may result from a variety of endobronchial lesions or by extrinsic bronchial compression, DR, Khaled M. Altaher MDCTL MRI Pathology v Endobronchial lesions that may cause obstructive atelectasis include mucus plugs, malpositioned endotracheal tubes, foreign bodies, endobronchial tumors, airway rupture, and/or areas of bronchial stricture or stenosis from various causes. Extrinsic bronchial compression and obstruction is usually caused by lymphadenopathy related to neoplastic disease but may also occur in patients with other diseases that affect hilar lymph nodes (e.g., tuberculosis, histoplasmosis, sarcoidosis). Nonobstructive atelectasis is related to various mechanisms encountered in the -atrization atelectasis. Relaxation atelectasis entities of relaxation, adhesive, and may either be caused by a space-occupying process that allows the lung to retract ina passive manner (e.g., pneumothorax) or one that compresses the lung (ie., a mass or a large pleural effusion). Adhesive atelectasis is related to surfactant deficiency, whether through an abnormality of the surfactant itself, in its local availability and distribution, or through insufficient surfactant production. The etiologies of adhesive atelectasis include the respiratory distress syndrome encountered in the pediatric population and the more common entity of postoperative atelectasis; the latter is a characteristic finding in patients following coronary artery bypass (CABG) surgery. Other causes include pneumonia, smoke inhalation, prolonged shallow breathing, pulmonary thromboembolism, acute radiation pneumonitis, and acute respiratory distress syndrome (ARDS). > Cicatricial atelectasis is an irreversible process related to underlying fibrosis, typically as a result of an infectious or inflammatory condition. As fibrous tissue within the DR, Khaled M. Altaher MDCTL MRI Pathology v lung retracts, there is resultant volume loss, and the same retractile forces may act upon airways within the involved parenchyma to produce traction bronchiectasis. Cicatricial atelectasis may be localized or diffuse. On imaging studies, the localized form is characterized by an increase in lung opacity/attenuation within an area of parenchymal distortion, often with associated foci of traction bronchiectasis. Adjacent areas of lung may appear hyperinflated in a compensatory fashion, and associated findings such as diaphragmatic elevation may be encountered. Diffuse cicatricial atelectasis is characterized on imaging by diffuse loss of volume in the affected lung, with associated parenchymal distortion and heterogeneous lung density. » Other forms of volume loss in the lungs include linear and rounded atelectasis. Linear atelectasis has also been referred to as discoid, plate-like, or subsegmental atelectasis. Such linear and band-like areas of atelectasis may be horizontal, oblique, or near vertical in their alignment and are most frequently encountered in the mid to lower lung zones. Rounded atelectasis is a unique form of volume loss that is typically associated with pleural thickening often related to previous asbestos exposure. It is also frequently found in patients with chronic pleural thickening related to other causes including previous thoracic surgery, notably involving the left hemithorax in patients with previous CABG surgery. Rounded atelectasis often mimics lung cancer on imaging studies by its characteristic formation of a subpleural mass, most often in the posterior aspect of either lower lobe. As in all cases of atelectasis, comparison with prior imaging studies is a key step in performing accurate radiologic interpretation DR, Khaled M. Altaher MDCTL MRI Pathology ° CT: » Evaluation of atelectatic lung with increased attenuation. v Identification of bronchovascular crowding & displacement of a fissure or fissures within the involved, > Evaluation of underlying etiology for complete atelectasis: Central tumor, mucus plug, extrinsic compression. v Evaluation of pleural space for pleural effusion or pneumothorax. Mediastinal shift toward the affected lung, compensatory hyperinflation of adjacent lung parenchyma hilar displacement, and elevation of the ipsilateral hemidiaphragm. The anterior mediastinal structures are more prone to shift in response to atelectasis than are the posterior structures, which are relatively tethered to the paraspinal tissues. Metastases * Pathways of metastatic spread from a primary extrathoracie site to lungs (in order of frequency): + Spread via pulmonary arteries + Lymphatic spread (Left) Axial CECT of a patient with metastatic renal cell carcinoma shows an ovoid, enhancing soft tissue lesion Flat the orifice of the left upper lobe (celiac nodes + bronchus with resultant left upper lobe atelectasis BEI& leftward . an mediastinal shift. (Right) Coronal oblique CECT of a patient with metastatic posterior mediastinal breast cancer shows a mass Eeithat completely occludes the left main bronchus. The presence of metastases elsewhere typically obviates the need for biopsy of a new endobronchial lesion in such patients DR, Khaled M. Altaher MDCTL MRI Pathology nodes + paraesophageal nodes). Lung parenchyma; + Direct extension &+ Endobronchial spread Neoplasms with rich vascular supply draining into systemic venous system: + Renal cell carcinoma,* Sarcomas, * Trophoblastic tumors, « Testis, + Thyroid Neoplasms with lymphatic dissemination: + Breast (usually unilateral), « Stomach (usually bilateral) Pancreas, + Larynx, Cervix Other neoplasms with high propensity to localize in hung: * Colon, * Melanoma, + Sarcoma Radiographic Features + Multiple lesions (95%) > solitary lesion. @ SN (Left) PA chest radiograph of a patient with metastatic melanoma shows right middle lobe consolidation. Endobronchial metastases are usually occult on radiography, but their effects (e.g., atelectasis, pneumonia) may be evident. CT is the imaging study of choice for assessment of suspected endobronchial metastases. (Right) Axial NECT of the same patient shows a mass lesion EYilling and obstructing the lumen of the bronchus intermedius. Biopsy confirmed metastatic melanoma I’ + Lung bases > apices (related to blood flow) + Peripheral (90%) > central. * Metastases typically have sharp margins. + Fuzzy margins can result from peritumoral hemorrhage (choriocarcinoma, chemotherapy). DR, Khaled M. Altaher MDCTL MRI Pathology * Cavitations are common in SCCs from head and neck primary lesions. * Calcified metastases Calcifications in lung metastases are observed in: + Bone tumor metastases, * Osteosarcoma, * Chondrosarcoma, * Mucinous tumors + Ovarian, « Thyroid, « Pancreas, * Colon, « Stomach, * Metastases afler chemotherapy Giant metastases (“cannon ball” metastases) in asymptomatic patient + Head and neck cancer, * Testicular and ovarian cancer, + Soft tissue cancer, * Breast cancer, * Renal cancer, * Colon cancer Sterile metastases This term refers to pulmonary metastases under treatment that contain no viable tumor. Nodules typically onsist of necrotic and/or fibrous tissue. Bronchiectasis © Irreversible dilatation of bronchus or bronchi, often with bronchial wall thickening * Morphology; Cylindrical, Varicose & Cystic bronchiectasis. DR, Khaled M. Altaher MDCTL MRI Pathology * Clinical Issues; Cough, sputum production, & hemoptysis * HRCT Dilated bronchi with bronchoarterial ratio > 1. Dilated bronchus > adjacent pulmonary artery Bronchial wall thickening & decreased attenuation on expiratory CT scans correlate with obstruction © Signet ring sign “V" or “Y” opacities or “finger in glove” sign; Mucus or secretions in bronchioles or bronchi © Bronchi not tapering appropriately &/or seen < | cm of costal or paravertebral pleura © Bronchial artery enlargement © Air-trapping, mosaic attenuation © Correlations suggest that obliterative bronchiolitis is cause for airway obstruction in bronchiectasis © HRCT of idiopathic bronchiectasis shows interlobular septal thickening in 60%, Possibly from impaired lymphatic drainage X 0 Traction bronchiectasis, distortion, & honeycombing in pulmonary fibrosis, DR, Khaled M. Altaher MDCTL MRI Pathology Imaging Recommendations © Best imaging tool; HRCT for diagnosis & characterization of severity & extent of bronchiectasis © Protocol advice; Expiratory imaging may confirm areas of obstructive physiology Pulmonary embolism * Diagnosis of pulmonary embolism (PE) can be challenging because the presenting symptoms are both common and nonspecific, including dyspnea, tachycardia, and pleuritic chest pain. © Most pulmonary emboli originate in the deep veins of the thighs and pelvis. The risk factors for deep venous thrombosis are widely Massive pulmonary embolism: CT pulmonary revalent in a hospital environment. angiogram shows a large, nearly-occlusive filling Prevalent in a hospita! environment, defect in the right main pulmonary artery including: Immobilization, malignancy, (arrows) extending proximally to the bifurcation. catheter use, obesity, oral contraceptive use, and thrombophilia * Approximately 25% of patents with PE don’t have any identifiable risk factor. * CT pulmonary angiogram is the most common method & the standard tool to image PE, where an embolism is typically seen as a central intraluminal pulmonary artery filling defect. a DR, Khaled M. Altaher MDCTL MRI Pathology Pulmonary emboli tend to lodge at vessel bifurcations. + An eccentric, circumferential filling defect suggests chronic thromboembolic disease. * Cardiac evaluation; Pulmonary embolism may cause acute right heart strain. After evaluation of the pulmonary arterial tree, one should always examine the heart for imaging findings of right heart dysfunction. + Massive PE may cause acute right ventricular dilation with bowing of the intraventricular septum to the left. An elevated RV:LV ratio (caused by RV enlargement) is linearly correlated with increased mortality. Pitfalls of CT pulmonary angiogram + Hilar lymph nodes may simulate large PE. * Cardiac motion causes blurring of the left lower lobe pulmonary arteries, which may simulate small peripheral emboli. + Respiratory motion decreases accuracy in evaluation of small pulmonary arteries. + Mucus-impacted bronchi may simulate PE + Transient disruption of contrast bolus occurs when unopacified blood from the IVC enters the right atrium and is pumped into the lungs. * Unopacified pulmonary veins may simulate PE on a single CT slice; however, one may distinguish between a pulmonary artery and vein by tracing the vessel back to the heart. Lung abscess Lung necrosis secondary to microbial infection. Evolution of consolidation from pneumonia to abscess cavity over 7-14 days DR, Khaled M. Altaher MDCTL MRI Pathology > Cavity: Air-containing lesion with relatively thick wall (> 4 mm) + surrounding consolidation or mass. Cough, foul-smelling sputum, periodontal disease cr; > Optimal visualization & assessment of lung abscess » Abscess may be fluid-filled > Air-fluid level or central air collection indicates bronchial communication > Cavity wall thickness: Variable, 4 mm to < 15 mm; thick wall more common, its Luminal interior wall usually smooth (90%), shaggy (10%) > Surrounding airspace or ground-glass opacity may show air bronchograms or tiny air bubbles > Abscess vs. empyema = Abscess: Thick, irregular wall, spherical, narrow contact with chest wall, broncho-vascular markings extend toward abscess + Empyema: Thin, uniform wall, lenticular shape, broad contact with chest wall, split pleura sign and adjacent compressed lung, > Reactive hilar & mediastinal lymphadenopathy common, usually < 2.5 cm short axis diameter DR, Khaled M. Altaher MDCTL MRI Pathology > Bronchopleural fistula: Development of hydropneumothorax, empyema. > Air crescent: Suggests invasive aspergillosis or mycetoma in preexisting cavity. © Lung infection caused by a variety of micro-organisms; Streptococcus pneumoniae is most common type of bacterial pneumonia, Consider pneumonococcal pneumonia in patient with fever, chills, productive cough, & & pli chet pio, chest pain. cr; > Consolidation frequently more extensive than expected based on radiography = Lobar consolidation most common \. par * Peribronchial consolidation also common in some series a ee > Ground-glass opacities frequently surround consolidation > Cavitation & abscess formation are rare = When present consider co-infection with anaerobic organisms or S. aureus > Pleural effusion & Lymphadenopathy in up to 50% of cases. DR, Khaled M. Altaher MDCTL MRI Pathology > CECT * Pleural effusion with pleural thickening & enhancement (“split pleura” sign) suggests empyema > HRCT = Centrilobular nodules, branching & tree-in-bud opacities = Diffuse bronchial wall thickening + interlobular septal thickening. 6- Liver; Hepatocellular carcinoma * HCC is the most common primary liver tumor. A hypervascular liver mass in a patient with cirrhosis or chronic hepatitis is an HCC until proven otherwise. * Alpha-feto protein (AFP) is elevated in approximately 75% of cases of HCC. * In the setting of cirrhosis, hepatocellular carcinoma (HCC) is thought to develop in a sequence from regenerative nodule to dysplastic nodule to HCC. Regenerative and dysplastic nodules cannot be reliably differentiated on imaging; and high-grade dysplastic nodules cannot be reliably differentiated from low- grade HCC. DR, Khaled M. Altaher MDCTL MRI Pathology © Regenerative nodule: is completely supplied by the portal vein and is not premalignant. A regenerative nodule should not enhance in the arterial phase. * Dysplastic nodule: is premalignant. However, most dysplastic nodules do not demonstrate arterial phase enhancement (unless high grade), since blood supply is still from the portal vein, * A siderotic nodule is an iron-rich regenerative or dysplastic nodule. A siderotic nodule is hyperattenuating on CT. It is rarely, if ever, malignant arterial phase enhancement is the characteristic imaging feature of HCC. However, between 10 -20% of HCCs are hypovascular and thus slightly hypoenhancing relative to surrounding liver on arterial phase imaging © The classic CT appearance of HCC is an encapsulated mass that enhances on arterial phase and washes out on portal venous phase. HCC may be difficult to detect on non-contrast or portal venous phase CT. * HCC is locally invasive and tends to invade into the portal veins, IVC, and bile ducts. In contrast, metastases to the liver are much less likely to be locally invasive. « Fibrolamellar HCC > Itis a subtype of HCC that occurs in young patients without cirrhosis. DR, Khaled M. Altaher MDCTL MRI Pathology > The tumor tends to be large when diagnosed, but has a better prognosis than typical HCC. Unlike in HCC, AFP is not elevated. > Unlike HCC, the fibrolamellar subtype does not have a capsule, although there may be a pseudocapsule of peripherally compressed normal hepatic tissue. Metastases © Although metastases are supplied by branches of the hepatic artery induced by tumoral angiogenesis, most metastases are hypovascular & best appreciated on portal venous phase (in contrast to HCC, which is hypervascular and best visualized on late arterial phase). © Hypervascular metastases (best seen on arterial phase) classically include: > Neuroendocrine tumors, including pancreatic, neuroendocrine tumors and carcinoid. Renal cell carcinoma, Thyroid carcinoma. Melanoma. Sarcoma. Colorectal and pancreatic adenocarcinoma metastases are typically hypovascular and can usually be diagnosed on portal venous imaging. ¢ Calcifications can be seen in mucinous colorectal tumors or ovarian serous tumors Calcification within a metastatic lesion may imply a better prognosis. * Pseudocirthosis describes the macronodular liver contour resulting from multiple scirrhous hepatic metastases, which may mimic DR, Khaled M. Altaher MDCTL MRI Pathology cirrhosis, Treated breast cancer is the most common cause of this appearance. Capsular retraction, although not always seen, is characteristic of pseudocirrhosis, and when present suggests pseudocirrhosis over cirrhosis. © Hypovascular metastases: Low-density center with peripheral rim or target-like enhancement > Hypervascular metastases: Hyperdense (intense) on arterial phase CECT, Cystic metastases (< 20 HU)CECT is usually best as “whole body" screening test > Even better if combined as PET/CT Metastases is common malignant tumor of liver, compared to primary malignant tumors. Pyogenic abscess © Hepatic abscess is most commonly caused by a bowel process and resultant infectious nidus carried through the portal system to the liver. Common causes include diverticulitis, appendicitis, Crohn disease, and bowel surgery. E. coli is the most common organism. A primary hepatobiliary infection, such as ascending cholangitis, may be a less common cause. DR, Khaled M. Altaher MDCTL MRI Pathology v Imaging features of hepatic abscess may mimic metastasis, appearing as a ring- enhancing mass on CT. Perilesional enhancement may be present. Hepatic fibrosis Itis overly exuberant wound healing in which excessive connective tissue builds up in the liver. The trigger is chronic injury, especially if there is an inflammatory component. Fibrosi itself causes no symptoms but can lead to portal hypertension. (the scarring distorts blood flow through the liver) or cirthosis(the scarring results in disruption of normal hepatic architecture and liver dysfunction). Various types of chronic liver injury can cause fibrosis (e.g., acute viral hepatitis A), hepatic fibrosis can regress if the cause is reversible (e.g., with viral clearance). After months or years of chronic or repeated injury, fibrosis becomes permanent. Fibrosis develops even more rapidly in mechanical biliary obstruction. CT; It can detect evidence of cirthosis and portal hypertension, such as splenomegaly and varices. However, they are not sensitive for moderate or even advanced fibrosis if splenomegaly and varices are absent, the heterogeneity of attenuation on CT are nonspecific and may indicate only liver parenchymal fat. Liver biopsy remains the gold standard for diagnosing and staging hepatic fibrosis and for diagnosing the underlying liver disorder causing fibrosis. However, liver biopsy is invasive, resulting in risk of minor complications (eg, postprocedural pain) DR, Khaled M. Altaher MDCTL MRI Pathology Vv v v and serious complications (eg, significant bleeding). Also, liver biopsy is limited by sampling error and imperfect interobserver agreement in interpretation of histologic findings. Thus, liver biopsy may not always be done. 7- Spleen; Splenomegal Splenic enlargement caused by a number of different underlying congestive, hematologic, inflammatory/infectious, neoplastic, or infiltrative disorders. Width and breadth are usually < 6 and 8 cm, respectively. Anteroposterior (AP) diameter < 2/3 AP diameter of abdominal cavity. Normal spleen is = 13 cm in length. Splenic index: Normally 120-480 cm? (product of length, breadth & width). Splenic weight: Splenic index X 0.55, normally100-250 g. CT; a splenic width measurement (largest anterior-posterior measurement on axial images) of greater than 10.5 cm is the most accurate single measurement for mild to moderate splenomegaly; while a cranio-caudal height measurement of greater than 14.6 emis the most accurate single measurement for massive splenomegaly. Pancreas; Pancreatic adenocarcinoma Pancreatic ductal adenocarcinoma makes up 80-90% of all pancreatic tumors. It is typically seen in patients over age 60, with a slight male predominance, Risk factors include smoking, 3% DR, Khaled M. Altaher MDCTL MRI Pathology alcohol, and chronic pancreatitis. CT; includes unenhanced, late arterial and portal venous phases images, The late arterial phase (pancreatic parenchymal phase) has the greatest conspicuity for detecting the classic hypoenhancing tumor against the background enhancing pancreas. The most common location of ductal adenocarcinoma is the pancreatic head. Since pancreatic adenocarcinoma is almost always associated with a dilated pancreatic duct, an alternative diagnosis should be strongly considered if there is a pancreatic mass with no ductal dilation, such as: Cystic pancreatic or neuroendocrine tumors, duodenal gastrointestinal stromal tumor (GIST)... Conversely, if the double duct sign is present but no mass is visible, one should still be suspicious for pancreatic adenocarcinoma. Approximately 10% of cases will be isoattenuating relative to pancreas in the pancreatic parenchymal (late arterial) phase and thus extremely difficult to directly detect. Pancreatic abscess Pancreatic abscess is an intra-abdominal collection of pus near the pancreas, and contains little or no necrosis. 7 DR, Khaled M. Altaher MDCTL MRI Pathology © Pancreatic abscess usually begin to form within 7-14 days after an episode of acute pancreatitis in 2-6%, but they may present much later. Approximately of patients with acute pancreatitis develop a pancreatic abscess, Abscesses may be suspected in patients with spiking fever. In suspected cases, CT is indicated for diagnosis and percutaneous drainage. In cases of failed percutaneous drainage, surgical intervention is indicated. Traumatic Pancreatic laceration * CT can diagnose pancreatic fractures, contusions, or posttraumatic pseudocysts, also can show thickening of the left anterior renal fascia, this sign should prompt a critical evaluation of the pancreas of the traumatized patient. The detection of the pancreatic injury may be difficult in patients who are scanned soon after injury, the actual plane of a pancreatic fracture may be difficult to identify and the peripancreatic soft-tissue changes of traumatic pancreatitis are often subtle. DR, Khaled M. Altaher MDCTL MRI Pathology 8- Abdominal wall & peritoneal cavity; Ascites * Ascites is the accumulation of free fluid in the peritoneal cavity. It could be due to benign causes where the fluid is observed primarily in the greater sac & not in the lesser omental bursae; whereas patients with malignant ascites tend to have proportional fluid collections in the greater & lesser sacs, it is suspected with hepatic, adrenal, splenic or lymph node lesions associated with masses arising from the gut, ovary or pancreas. * Ascites is demonstrated well on CT scan images, small amount of ascetic fluid localize in the right perihepatic space. The posterior subhepatic space (Morison pouch) and Douglas pouch. A number of CT features suggest neoplasia. > In most cases, the attenuation of the ascites is that of clear fluid, measuring around 0 HU., if the attenuation of ascetic fluid is significantly greater than 0 HU, this should raise concern for hemorrhage or SBP. Hemoperitoneum © There are numerous causes of hemoperitoneum in both traumatic and nontraumatic settings. Trauma-related injury toa solid organ, particularly to the liver or spleen, is by far the most common cause of hemoperitoneum hemorrhage DR, Khaled M. Altaher MDCTL MRI Pathology from a tumor, rupture of an ovarian cyst or of the affected anatomy in an ectopic pregnancy, and iatrogenic bleeding as a result of surgery or other therapy. The most dependent portion of the abdomen is the hepatorenal fossa (Morison pouch), and the most dependent portion of the pelvis is the pelvie cul-de-sac (pouch of Douglas). © Hemoperitoneum starts near the site of injury and flows along expected anatomic pathways. CT is the imaging modality of choice because of its ability to help distinguish blood from other fluids. The crucial initial steps are to use the various CT signs to detect the presence of intraperitoneal blood, locate the source of hemorrhage, and determine whether emergent intervention is indicated. Attenuation measurements at CT can help differentiate among simple ascites, unclotted blood from recent bleeding, hematoma, bile, urine, chyle, and active bleeding After these steps are completed, a differential diagnosis may be generated on the basis of the clinical history and radiologic findings Subphrenic abscess Itis a disease characterized by an accumulation of infected fluid (pus) between the diaphragm, liver, and spleen. This abscess may be secondary to: Peritonitis, perforated peptic or a typhoid ulcer, or appendicitis, ruptured a hollow viscus or amoebic liver abscess, PID or infection following surgical operations. © Presents with cough, increased respiratory rate with shallow DR, Khaled M. Altaher MDCTL MRI Pathology respiration, diminished or absent breath sounds, hiccups, dullness in percussion, tenderness over the 8th-I Ith ribs, fever, chills, anorexia and shoulder tip pain on the affected side, Lack of treatment or misdiagnosis could quickly lead to sepsis, septic shock, and death, It is also associated with peritonitis 9- Retroperitoneal ; Aortic atherosclerosis Abdominal aortic aneurysm (AAA) is relatively prevalent in older men and less common in women. Rupture of abdominal aortic aneurysm is the 13th leading cause of death. (AAA) is defined as an aortic diameter >3 cm. Similar to measurement of thoracic aortic aneurysms, double-oblique reformatted images should be used to obtain a true cross- sectional diameter. Volume measurement can also be used to monitor for endoleak on follow-up. The natural history of (AAA) is progressive enlargement and eventual rupture. Atherosclerosis is a condition where the arteries become narrowed and hardened due to a buildup of plaque around the artery wall. DR, Khaled M. Altaher MDCTL MRI Pathology Abdominal Aorta aneurysm & dissection * Aortic dissection represents a spectrum of processes in which blood enters the muscular layer (media) of the aortic wall and splits it in a longitudinal fashion. Most dissections are spontaneous and occur in the setting of acquired or inherited degeneration of the aortic media (medial necrosis). Medial necrosis occurs most commonly as an acquired lesion in middle-aged to elderly hypertensive patients. Dissections (spontaneous) almost exclusively originate in the thoracic aorta and secondarily involve the abdominal aorta by extension from above. Aortic dissection results in the separation of two lumens by an intimal flap. The false lumen represents the space created by the splitting of the aortic wall; the true lumen represents the native aortic lumen. In chronic dissections the false channel may become ancurysmal. © CT Features > Dynamic contrast-enhanced helical CT is the es technique of choice. Key diagnostic finding: intimal flap > Delayed contrast-enhanced helical CT (occasionally needed). DR, Khaled M. Altaher MDCTL MRI Pathology v Precontrast scan to detect wall hematoma (hyperdense wall) T is more accurate in detection of: Thrombosed false channels, Two lumens (true and false); = Delayed opacification of false lumen = Compression of true lumen by false lumen Occlusion of branch vessels Thrombosis of IVC High-speed MDCT has the potential to replace traditional imaging techniques in the evaluation of pathologic processes involving the IVC. The ability to acquire near-isotropic data allows high-quality reconstructions in the sagittal and coronal planes and thus overcomes one of the major limitations of CT in evaluating the IVC. The ideal imaging modality to help diagnose an IVC anomaly must have high diagnostic aS ., wo accuracy & also be safe and reproducible. One of the more common and helpful clues is well-developed and possibly dilated intrathoracic hemiazygos or azygos continuations. These collateral circulations, as well as other retroperitoneal venous pathways, are usually well developed before symptoms present. DR, Khaled M. Altaher MDCTL MRI Pathology © The most reliable noninvasive methods for establishing a diagnosis of IVC anomalies are computed tomography (CT) with intravenous (IV) contrast. CT is a good imaging modality for the retroperitoneal space. * CT scans are often obtained as part of the diagnostic evaluation for the primary process (e.g, malignancy). The use of IV contrast materials is typically required. Pseudothrombosis, particularly of the infrarenal IVC, is generally thought to result from the variable amounts of contrast in the cava above and below the renal veins. It may also result from collapse of the IVC at the diaphragm when patients are supine. 'soas hematoma & abscess © The psoas muscle originates from the transverse processes of T12 & the lumbar vertebrae and extends inferiorly to merge with the iliac muscle at the LS-82 level, becoming the iliopsoas muscle which passes beneath the inguinal ligament to insert on the lesser trochanter of the femur. Psoas abscesses generally do not DR, Khaled M. Altaher MDCTL MRI Pathology originate within the psoas compartment but spread here from neighboring intraabdominal structures that have a pyogenic infection. Primary abscesses rarely occur and are usually idiopathic. The organisms are typically Staphylococcus aureus and mixed gram-negative organisms, Tuberculous psoas abscesses are increasing in incidence and they are frequently associated with evidence of Pott's disease. When it is localized in a paraspinal location, a psoas abscess may be revealed by its effacement of the lateral border of the muscle and its lateral displacement of the kidney and ureter. CT images show enlargement of the muscle with fluid collections, ring enhancement, and perhaps gas. Injection studies confirm clinical observations that the strong psoas fascia confines collections within it. Indeed, this may provide a pathway for extension of the process to the hip and thigh. Hemorrhage into the psoas muscle can be spontaneous (arteriosclerosis) or secondary to trauma, bleeding diathesis, anticoagulant therapy, inflammatory disease, tumor, or recent surgery or biopsy. CT; may present simply as an enlarged psoas muscle acute blood will present as an area of high density +/- fluid-fluid level chronic haematomas may have a similar appearance to psoas abscess DR, Khaled M. Altaher MDCTL MRI Pathology 1l1- Kidney & ureter; Stones © Definitions; Coneretions within urinary system © Presentation; > Upper UT: Asymptomatic, flank pain, fever > Ureteral calculi; Acute colicky flank pain radiating to groin > Lower UT: Asymptomatic, dysuria, dull/sharp pain radiating to penis, buttocks, perineum, or scrotum > MF=3:1 > Natural History & Prognosis = Spontaneous passage through ureter: 80% (< 4 mm), 50% (4-6 mm), 20% (> 8 mm) = Complications: Obstruction, infection, abscess, and renal insufficiency = Prognosis: Recurrence without treatment: 10% at 1 year, 35% at 5 years, 50% at 10 years. * CT Findings > NECT = Ureteral calculi; <4 mm with soft tissue rim sign, Hydroureteronephrosis and perinephric stranding. = Calculi are all uniformly dense except matrix and indinavir stones DR, Khaled M. Altaher MDCTL MRI Pathology = Radiopacity: Calcium oxalate &/or phosphate > cystine > struvite > uric acid = Calcium calculi: 400-600 HU, Uric acid and cystine calculi: 100-300 HU = Milk of calcium: Layered opaque suspension; stone movement in calyceal diverticulum Indinavir calculi: Not or faintly opaque; deduced from secondary findings (obstruction) Ureteral calculi — Soft tissue rim sign: Ureteral wall edema at calculus — Pseudoureterocele: UVJ edema around calculus ~ Hydroureteronephrosis: Perinephric stranding > CECT = Lucent filling defects (matrix and indinavir stones) during excretory phase > Dual-energy CT (DECT) = Calculi have different attenuation values when imaged at low and high energies. = Analysis of energy-dependent changes in attenuation allow determination of chemical composition. — Stone analysis is compared to referenced material- specific attenuation curves. = Specificity of chemical composition decreases with; Small (<3 mm) calculi & large patient body habitus. DR, Khaled M. Altaher MD. vov CTL MRI Pathology Horse shoe kidney Definitions; Congenital anomaly in which kidneys arise on wrong side, fused by isthmus at their lower poles, It is composed of normal parenchyma (more common) or connective tissue; both ureters cross midline to insert into bladder Location Ectopic, lies lower than normal kidneys Isthmus usually anterior to aorta and caudal to confluence of iliac veins, Rarely, anterior to aorta and dorsal to inferior vena cava (IVC) 2 types of fusion; Midline or Lateral. CT Findings CECT multiplanar and 3D reconstructions = Defines structural abnormalities, Degree and site of fusion: Midline or lateral fusion ~ Shows degree of renal malrotation — Renal parenchymal changes (e.g., scarring, cystic disease) — Collecting system abnormalities (e.g., duplex system, hydronephrosis) DR, Khaled M. Altaher MDCTL MRI Pathology = Differentiate composition of isthmus between fibrous or normal functioning parenchyma > CTA 3D volume-rendered CT to better define vessels = Variant arterial supply — Multiple, bilateral renal arteries — Arteries arising from aorta or common iliac, internal iliac, external iliac, or inferior mesenteric arteries Inferior mesenteric artery always crosses isthmus * Complications > Traumatic injury, isthmus lies anteriorly without protection by ribs > split by hard blow to abdomen > UPJ obstruction: , Recurrent infections, Vesicoureteral reflux, Urolithiasis. > Wilms tumor in children & Primary renal cell carcinoma: t prevalence Pelvic kidney * Abnormal kidney location in true pelvis, below iliopectineal line due to developmental anomaly; Left (70%) > right; if bilateral, left usually inferior to right kidney and generally fused > May see anomalies of rotation > Ureter frequently too high, May ectopic ureter, extrarenal calyces © CT Findings; Differentiate it from various pelvic masses. DR, Khaled M. Altaher MDCTL MRI Pathology * CTA; Often multiple renal arteries, usually arise from distal end or aortic bifurcation. * Congenital outpouchings from the renal calyx or pelvis into the renal cortex. The majority of cases are asymptomatic and discovered incidentally on imaging. © Onnephrographie phase CECT, a calyceal diverticulum will have an appearance similar to that of a simple cyst. The diagnosis is made with certainty in the excretory phase when the cystic structure fills with contrast material due to communication with the collecting system, and layering of contrast material is seen within. This helps differentiate it from a renal cyst, which does not connect with the collecting system. * Complications; Iculi or layered dependent milk of calcium will be hyperattenuating on an unenhanced CT. Pyelonephritis Acute Pyelonephritis; © It is a bacterial infection of the renal pelvis and parenchyma most commonly seen in young women. DR, Khaled M. Altaher MDCTL MRI Pathology Vv Clinical presentation; A rapid onset of high fever and flank pain and tenderness. Less specific or non- urinary symptoms and signs may also be present, which may lead to clinical confusion. Infection gains access to the upper urinary tract by passing retrograde up the ureter from the bladder. The infection then passes into the collecting tubules and results in an interstitial nephritis, with resulting alterations in renal filtration and blood flow in the affected region. Localised ischaemia secondary to inflammatory changes results in altered imaging and may eventually lead to necrosis and scar. Rarely, the kidney may be seeded haematogenously. CT; is a sensitive modality for evaluation of the renal tract. Unfortunately, it does have a significant radiation burden and should be used sparingly. Non-contrast CT = often the kidneys appear normal, affected parts of the kidney may appear oedematous, i.e, swollen and of lower attenuation, renal calculi or gas within the collecting system may be evident CECT = One or more focal wedge-like regions will appear swollen and demonstrate Wedge-shaped or rounded areas of poor/streaky enhancement. The periphery of the cortex is also affected. DR, Khaled M. Altaher MDCTL MRI Pathology = Best identified on nephrographic &/or excretory phase if imaged during the excretory phase, a striated nephrogram may also be visible. If for some reason the kidney is imaged again within 3-6 hours, persistent enhancement of the affected regions may be evident due to slow flow of contrast through the involved tubules. = Perinephric inflammatory changes; Thickening of Gerota fascia, Perinephric fat stranding and fluid , Renal & perirenal abscess. = Localized or generalized swelling — Unilateral or bilateral (less common); Small areas of pyelonephritis may be missed on corticomedullary phase images — Occasionally mass-like; may distort normal renal contour — Findings may persist after clinical improvement Chronic Pyelonephritis; © Renal scarring and shrinkage secondary to multiple episodes of acute pyelonephritis during early childhood Most cases are secondary to vesicoureteral reflux. * CT Findings: Segmental thinning of cortex and medulla (typically in poles) Hypertrophy of residual normal tissue (can mimic mass) Blunting of calyces (secondary to retraction of papilla) vVwvy Dystrophic calcification DR, Khaled M. Altaher MDCTL MRI Pathology Obstructed ureter * Definitions; Obstruction of ureteral lumen due to intraluminal, intramural, or extrinsic process, e.g,, retroperitoneal metastases, fibrosis or malignancy, Urolithiasis (Renal Calculi) & Tuberculosis. » Vasculitis ischemia — fibrosis = CT: Ureteral wall thickening; calcification may be seen > Ureteral Transitional Cell Carcinoma = CT Findings; Intraluminal ureteral soft tissue lesion (30-60 HU), Variable enhancement of tumor, Ureteral dilatation at level of lesion and upstream, Renal TB © Tuberculosis remains the most common worldwide cause of mortality from infectious disease. Genitourinary system is one of the most common sites of involvement by extrapulmonary tuberculosis, It results from hematogenous seeding of Mycobacterium tuberculosis in the glomerular and peritubular capillary bed from a pulmonary site of primary infection tuberculosis. Small granulomas form in the renal cortex bilaterally, adjacent to the glomeruli, Granuloma formation, caseous necrosis, and cavitation are eH DR, Khaled M, Altaher MDCTL MRI Pathology vowvvyv stages of progressive infection, which can eventually destroy the entire kidney. Communication of the granulomas with the collecting system can lead to regional spread of the bacilli into the renal pelvis, ureters, urinary bladder, and accessory genital organs, The host’s healing response induces fibrosis, calcium deposition, and stricture formation, which may contribute significantly to obstruction and progressive renal dysfunction. Imaging findings| Neerotie lesions, Strictures (ureter, infundibulum, pelvis). Caliectasis; hydronephrosis. Calcifications (punctate, linear, curvilinear, diffuse) "Putty kidney": End-stage infection associated with diffuse calcifications (autonephrectomy). CT is helpful in determining the extent of renal and extrarenal spread of disease. CT is the most sensitive modality for identifying renal calcifications. Coalesced cortical granulomas containing either caseous or calcified material are readily identified. Calices that are dilated and filled with fluid have an attenuation between 0 and 10 HU; debris and caseation, between 10 and 30 HU; putty-like calcification, between 50 and 120 HU; and calculi, greater than 120 HU, Cortical thinning is a common, may be either focal or global, Parenchymal scarring, strictures of the infundibula, renal pelvis, and ureters may be seen at CECT and are highly suggestive of tuberculosis, es DR, Khaled M. Altaher MDvvvyv CTL MRI Pathology 12- Adrenal glands; Adrenal carcinoma Rare & highly malignant neoplasm of adrenal cortex. Large, solid, unilateral adrenal mass with invasive margins (bilateral in 10%), usually unilateral and contain hemorthagic, cystic & calcified areas. Rarely symptomatic incidental imaging finding Local spread: Renal vein, inferior vena cava (IVC) Metastatic spread: Lungs, liver, nodes, bone. Metastatic at presentation in 20%. Mostly stage III or IV at time of diagnosis; due to early invasion of renal vein or IVC Functioning (< 50%); nonfunctioning (> 50%) = Size; Functioning: Usually 5 cm at presentation & Nonfunctioning: > 10 cm. y sa CT Findings Solid, well-defined suprarenal mass + invasive margins. Usually unilateral. + areas of necrosis, hemorrhage, rarely fat & Calcification seen in 30%, Variable enhancement (necrosis and hemorrhage). DR, Khaled M. Altaher MDCTL MRI Pathology vov v + venous invasion, renal vein and IVC. + invasion into adjacent renal parenchyma. > Metastases to lung bases, liver, or nodes. Washout kinetics similar to adrenal metastases. Adrenal metastases Discrete or diffuse soft tissue attenuation suprarenal masses in patient with history of extra-adrenal malignancy. Unilateral or bilateral; small or large. 4th most common site of hematogenous metastases after lungs, liver, and bone Most common primary sites; Malignant melanoma, Lung and breast cancers & Renal and GI tract malignancies. Direct extension into adrenals from tumors in adjacent organs; Kidney, pancreas, stomach, liver, retroperitoneum. CT Findings; Small metastases © Unilateral or bilateral, Well-defined, round or oval in shape, Adrenal gland contour may be maintained. 3 DR, Khaled M. Altaher MDCTL MRI Pathology v © Homogeneous soft tissue attenuation masses © Necrosis, hemorrhage, and calcification are rare © May mimic lipid-poor adrenal adenoma on NECT. Large metastases © Unilateral or bilateral adrenal masses © Distortion of normal contour of adrenal gland, lobulated or irregular in shape. © Heterogeneous density (necrosis, hemorrhage), calcification & thick enhancing rims © Hypervascular or hypovascular ‘© Uncommon invasion of contiguous organs © Prolonged washout pattem on CECT; more than 15 minutes suggests metastasis or other "nonadenoma’, Hypervascular adrenal metastases (HCC, RCC) may have rapid washout pattern similar to li -poor adenomas. 13- Pelvis; Ovarian cyst They are commonly encountered in gynaecological imaging, and vary widely in aetiology, from physiologic, to complex benign, to neoplastic, Small cystic ovarian structures should be considered normal ovarian follicles unless the patient is pre-pubertal, post- menopausal, pregnant, or the mean diameter is >3 em. 2 DR Khaled M. Aliaher MDCTL MRI Pathology Types of cysts Physiological cysts: mean diameter <3 cm; ovarian follicle & corpus luteum, Functional cysts (can produce hormones); follicular cysts of the ovary (oestrogen): >3 cm, corpus luteum cysts (progesterone), theca lutein cyst: gestational trophoblastic disease & complications in functional cysts (haemorrhage, enlargement, rupture & Torsion). Other cysts: (multiple large ovarian cysts in ovarian hyperstimulation syndrome, post-menopausal cyst: serous inclusion cysts of the ovary, polycystic ovaries, ovarian torsion & ovarian cystic neosplasms. cT Dermoid cyst; Fatty mass with low HU, Fat-fluid level & Calcifications: tooth, rim calcification. Simple cysts: hypodense, intraovarian or exophytic; have an imperceptible wall or a visible far wall, variable size, may be large enough to obscure the ovary from which it is arising. If the size >5 and <7 cm; increased risk of ovarian torsion. Endometriosis It is a common and clinically important problem in women of childbearing age. It is classically defined as the presence of functional endometrial glands and stroma outside the uterine cavity and its musculature. This is distinct from adenomyosis. 2 DR, Khaled M. Altaher MDCTL MRI Pathology v v v Clinical presentation Infertility, pelvic pain (not always cyclic): including dyspareunia, dysmenorrhea, chronic pelvic pain, tenderness along the adnexa and uterosacral ligaments, cul-de-sac +/- thickening or nodularity, rectovaginal or adnexal masses. Location The most common locations for endometriotic deposits are the ovaries, then in the pelvic peritoneum, the pouch of Douglas, uterosacral ligament. Less common locations include -section scars (scar endometriosis), deep subperitoneal Computed Tomography CT scanning typically is not performed in the radiologic evaluation of endometriosis because the appearance of endometriosis and endometriomas on CT scans is nonspecific. If CT scanning is performed, endometriomas appear as cystic masses. A slightly high attenuation crescent lying dependently within the cyst has been described as a more specific feature. Complications of endometriosis, such as bowel obstruction, are evident on CT scans. Ureteral obstruction may cause hydronephrosis. The appearance of endometriomas and endometriosis on CT scans is easily mimicked by pelvic inflammatory disease, as well as by benign or malignant ovarian tumors. 3 DR, Khaled M. Altaher MD