Genitourinary Radiology

Original Article

Grand J Urol 2022;2(1):15-20, DOI: 10.5505/GJU.2022.87599

Relationship Between SUVmax and ADC Values of Metastatic Lymph Nodes Detected by Ga-68 PSMA PET/MR in Prostate Cancer Patients

Fuad Aghazada, Ali Kibar, Rabia Lebriz Uslu Besli, Muhammet Sait Sager, Haluk Burcak Sayman, Kerim Sonmezoglu

Objective: Our aim is to assess if there is a relationship between maximum standardized uptake (SUVmax) and apparent diffusion coefficient (ADC) values of reactive and metastatic lymph nodes, also to compare ADC values of reactive and metastatic lymph nodes in prostate cancer patients. Materials and Methods: We have retrospectively investigated 20 patients diagnosed with prostate cancer who underwent Ga-68 PSMA PET/MR imaging. Three metastatic and three reactive lymph nodes classified according to the level of PSMA Ga-68 uptake in PET/MR were chosen for each patient. SUVmax and ADCmean values were calculated for each lymph node separately. SPSS version 22 was used for statistical analysis. Results: A total of 120 lymph nodes in 20 prostate cancer patients were assessed. There was a moderate negative correlation between SUVmax values and ADCmean values of metastatic lymph nodes (p=0.009, r=-0.333). However, there was no significant correlation between SUVmax values and ADCmean values of reactive lymph nodes. ADCmean values of metastatic lymph nodes were significantly lower than those of reactive lymph nodes (p=0.0001). Conclusion: PET/MR, which combines both advantages of PET and MRI, is an important tool for the diagnosis and management of prostate cancer. We have found that SUVmax values of metastatic lymph nodes were inversely correlated with ADCmean values and combination of both parameters may increase the diagnostic accuracy of Ga-68 PSMA PET/MR in the detection of lymph node metastasis.

Clinical Image

Grand J Urol 2021;1(1):37-38, DOI: 10.5222/GJU.2021.66376

Isolated Adrenal Gland Injury After Blunt Trauma

Ramazan Azar, Yurdagul Cetin Seker, Kamil Gokhan Seker, Ismail Taskent

A 36-year-old male patient was admitted to the emergency department with abdominal and left side pain 1.5 hours after an in-vehicle traffic accident. The patient had no history of comorbidity or surgery. The patient did not receive any anticoagulant or antiplatelet therapy prior to the trauma. Vital signs of the patient were stable (Blood pressure 145/100 mmHg, pulse 98 beats/min, and temperature 37.2°C). Physical examination revealed no additional pathology except left side pain and left upper quadrant tenderness in deep palpation. White blood cells were found to be 17.330/mm3, hemoglobin level 17.34 mg/dL, and hematocrit 48.83% in the complete blood count examination. There was no abnormality in the biochemical analysis. An evaluation focused on sonography for trauma (FAST) in the emergency department was negative. Contrast-enhanced thoracoabdominal computed tomography (CT) scan was performed. Abdominal CT revealed a 44x42 mm left central hyperdense and peripheral hypodense adrenal mass (63 hounsfield unit) and periadrenal fat strands. Additionally, a cortical cyst was observed in the upper pole of the left kidney (Figure 1). The lesion was evaluated as an adrenal hematoma. No other injuries were detected, especially no injury to the spleen or kidney. No rib or spine fractures were observed. The patient was treated conservatively with bed rest, parenteral fluid, antibiotherapy, and analgesics. Hemoglobin and biochemical parameters remained constant. Endocrinology consultation was requested for adrenal insufficiency. Endocrinological evaluations revealed no pathology. The control abdominal CT performed 7 days later showed that the hematoma did not progress (40x37 mm, central density is prominent) (Figure 2). The patient was discharged without any problems. An abdominal CT scan was planned to evaluate the resolution of the adrenal hematoma 1 month later. The patient was asymptomatic during the follow-up. No abscess or infection format was observed. Informed written consent was obtained from the patient for this report. Figure 1: A- Left adrenal hematoma 44x42 mm attenuated central hyperdense and peripheral hypodense round mass in the adrenal gland, B- Periadrenal fat stranding, C- Left kidney upper pole simple cortical cyst (Axial view of enhanced abdominal CT scan) Figure 2: Control abdominal CT; regression of hematoma and increased appearance of central hyperdensity (Axial view of enhanced abdominal CT scan) Adrenal gland injury is a rare clinical picture caused by motor vehicle accidents, sports injuries, or blunt abdominal trauma after falling [–]. Isolated adrenal gland injury is rare due to its small size, deep retroperitoneal position on the upper abdomen, and presence of full-fat tissue around it. Most adrenal gland injuries are associated with multiple adjacent skeletal and organ injuries []. Adrenal gland injuries have been reported in approximately 2-3% of all thoracoabdominal injuries []. Unilateral adrenal injuries occur 5 times more on the right side than on the left (77% versus 15%), and bilateral adrenal injuries occur in 8% of cases in trauma []. Being usually silent and self-limiting, it does not require major operative intervention. However, it may be potentially life-threatening in some cases. The most common symptom is pain; other clinical presentations vary greatly, and it does not produce any specific symptoms or biomarkers. Abdominal pain, side pain, nausea, vomiting, hypotension, hypertension, a palpable side mass, agitation, mental status changes, and lowgrade fever may occur []. The emergency physician should be aware of the possibility of organ damage associated with adrenal injury and the potential for adrenal insufficiency especially if an unusual complaint is presented after blunt trauma (unexplained hypotension, electrolyte disorder, and pain that does not go away despite analgesics) []. Although ultrasonography is noninvasive, easily accessible, and inexpensive, it is dependent on the person and can sometimes be inadequate when evaluating retroperitoneal organs. CT is the gold standard for detecting adrenal gland injury as in all trauma cases []. CT scan findings of adrenal gland injury include hyperdensity, periadrenal fat stranding infiltration, and ipsilateral diaphragmatic crural thickening [,]. Furthermore, the need to monitor and rule out an underlying adrenal neoplasm should be taken into account in these patients due to possible bleeding to a pre-existing adrenal mass []. Surgery (adrenalectomy) and interventional radiologic procedures (embolization) may be needed although most adrenal gland injuries are treated conservatively. Treatment depends on the hemodynamic condition of the patient, the severity of the gland damage, bilateral gland involvement, and the extent of bleeding within the gland []. Ethics Committee Approval: N / A. Informed Consent: An informed consent was obtained from the patient. Publication: The results of the study were not published in full or in part in form of abstracts. Peer-review: Externally peer-reviewed. Conflict of Interest: The authors declare that they have no conflict of interest. Financial Disclosure: The authors declare that this study received no financial support.

Grand J Urol 2021;1(2):81-82, DOI: 10.5222/GJU.2021.09609

Multipl Masses Diagnosed as Oncocytoma in Both Kidneys

Mustafa Orhan Nalbant, Omer Yildiz, Elif Hocaoglu, Ercan Inci

A 67-year-old male patient who had multiple solid masses in both kidneys in another center ultrasound examination was referred to our clinic for further examination. He had no known chronic or syndromic disease. The patient was evaluated with dynamic contrast enhanced upper abdominal magnetic resonance imaging (MRI). In MRI, homogeneous enhancing solid lesions with hypointense central stellate scar and non-enhancing cysts was seen in both kidneys. Diffusion restriction was observed in the periphery of the solid lesion in the lower pole of right kidney which was considered suspicious for malignancy and biopsy was performed from this lesion (Figure 1). Pathology result reported as oncocytoma so follow-up decision was made for the patient. In the follow-up, the masses in the left kidney increased in size and diffusion restriction developed in the upper pole of the left kidney (Figure 2). This lesion was also biopsied because of suspect imaging finding, the result was reported as oncocytoma as well. At the same time, the patient was evaluated for tuberous sclerosis and Birt-Hogg-Dube syndrome as they associated with multiple bilateral oncocytomas. There was no similar signs, semptoms and imaging findings related to these genetic syndromes in the family members of the patient. Informed written consent was obtained from the patient for this report. Figure 1: A-Homogeneous enhancing, B- Multipl solid lesions with hypointense central stellate scar and non-enhancing cysts in both kidneys, C- Diffusion restriction was observed in the periphery of the solid lesion in the lower pole of right kidney (Coronal and axial view of enhanced abdominal MRI) Figure 2: A- Although having homogeneous enhancement with hypointense central stellate scar, B- Solid lesions in the left kidney increased in size, C- Peripheral diffusion restriction developed in the upper pole of the left kidney on follow-up MRI (Coronal and axial view of enhanced abdominal MRI) Renal oncocytoma is a benign renal tumor and up to three-quarters of patients with a renal oncocytoma are asymptomatic []. So its diagnosis is incidental on abdominal imaging. Possible signs and symptoms of a renal oncocytoma include hematuria, flank pain and an abdominal mass []. Both oncocytomas and renal tumors show similar enhancement but the central scar and the inversion pattern of enhancement have been associated with oncocytomas []. The "central stellate scar" sign refers to a central zone of fibrous connective tissue, with the bands of fibrosis radiating toward the periphery of the lesion is a characteristic radiological finding described of renal oncocytoma []. Central scar cannot be distinguished on imaging from the necrosis commonly found in renal cell carcinoma []. The underlying cause of most isolated renal oncocytomas is unknown; however, multiple oncocytomas can occur in people with certain genetic syndromes such as tuberous sclerosis and Birt-Hogg-Dube syndrome. Isolated oncocytomas usually seen as a single tumor affecting one kidney, on the other hand renal oncocytomas that are part of a genetic syndrome often affects both kidneys with multipl tumors [,]. Renal oncocytomas which are part of a genetic syndrome are associated with mutations. Birt-Hogg-Dube syndrome is caused by mutations in FLCN gene while tuberous sclerosisis caused by mutations in the TSC1 or TSC2 genes []. It can be hard to distinguish oncocytoma from renal cell carcinoma with only imaging studies. Biopsy is often needed to confirm the diagnosis []. Most patients are treated with surgery to confirm the diagnosis since the distinction between oncocytoma and renal cell carcinoma can not be made with imaging methods alone. Whether oncocytoma is strongly considered, partial nephrectomy can be done as a more conservative method []. Ethics Committee Approval: N/A. Informed Consent: An informed consent was obtained from the patient. Publication: The results of the study were not published in ful lor in part in form of abstracts. Peer-review: Externally peer-reviewed. Conflict of Interest: The authors declare that they have no conflict of interests. Financial Disclosure: The authors declare that this study received no financial support.

Grand J Urol 2021;1(3):150-151, DOI: 10.5222/GJU.2021.09797

The Eternal Dilemma: Fat-poor Angiomyolipoma

Omer Yildiz, Mustafa Orhan Nalbant, Elif Hocaoglu, Ercan Inci

A 55-year-old female patient admitted to the emergency department with one week long abdominal pain. In the physical examination of the patient, no clinical finding other than sensitivity was observed. The laboratory tests were normal. Because there was discordance between the patients clinical findings and laboratory tests, ultrasound exam was performed to exclude acute abdomen and a mass was detected in the anterior of left kidney's upper pole. There upon, the patient was discharged with recommendations and directed to the urology department. The patient had no history of malignancy or surgical history. Contrast enhanced abdominal magnetic resonance (MR) was performed for the lesion characterization. In the abdominal MRI, a lesion was detected in the anterior region of the left kidney's upper pole which is 36x20 mm in size. The lesion was hypointense on T2 weighted images (WI), slightly hyperintense on T1WI and had central cystic area. Since the mass was closely adjacent to the tail of the pancreas and had similar signal intensity with the pancreas on T2WI and postcontrast images, the origin of the lesion could not be made clearly between left kidney and pancreatic tail (Figure 1-5). Therefore, histopathologic verification was recommended for preoperative management. It was reported as angiomyolipoma, wihch is rich in smooth muscle and poor in fat, after staining with actin and HMB-45 along with immunohistochemical staining obtained as a result of the biopsy procedure. Figure 1: Axial T2 weighted (Contrast-enhanced abdominal magnetic resonance images of the patient) Figure 2: In phase (Contrast-enhanced abdominal magnetic resonance images of the patient) Figure 3: Out of phase (Contrast-enhanced abdominal magnetic resonance images of the patient) Figure 4: T1 Weighted, fat saturated T1 weighted (Contrast-enhanced abdominal magnetic resonance images of the patient) Figure 5: Post contrast images revealed a solid mass with central cystic area (Contrast-enhanced abdominal magnetic resonance images of the patient) Renal angiomyolipomas are the most common benign kidney tumors. Non invasive diagnostic capacity between benign and malignant lesions is not yet at the desired standard. Approximately 10-17% of the resected kidney tumors are benign, and 2-6% of them are reported as angiomyolipomas []. Angiomyolipomas contain smooth muscle tissue, blood vessels and macroscopic fat areas in varying proportions []. In most cases, it is diagnosed radiologically without any further examination due to the macroscopic fat content. In the radiological diagnosis of angiomyolipoma, we use findings such as containing densities below -10 HU in computerized tomography (CT) examination or showing suppression in fat saturated sequences in MRI []. In addition, chemical shift suppression techniques are useful in MRI in cases when there is a small amount of fatty tissue []. On the other hand, in 4.5% of angiomyolipomas, fatty tissue may not be seen radiologically []. Since the imaging findings of these fat-poor lesions, containing less than 25% fat, cannot be distinguished from RCC and they pose a serious problem []. RCCs, especially clear cell carcinomas, may also contain fat, but unlike angiomyolipomas, this adipose tissue is located at intracellular space and we use signal loss in out of phase MR sequence to differentiate RCC from angiomyolipoma []. Angiomyolipomas carry the risk of bleeding, especially in sizes over 4 cm and sometimes, fat densities can be overlooked due to intralesional bleeding and they can be confused with RCC []. Although new methods such as CT histogram [] and specific MR sequences [,] have been used in the separation of fatpoor angiomyolipoma and RCC with new developments in radiology and technology, the application and reliability of these methods in daily practice are not sufficient. Ethics Committee Approval: N/A. Informed Consent: An informed consent was obtained from the patient. Publication: The results of the study were not published in ful lor in part in form of abstracts. Peer-review: Externally peer-reviewed. Conflict of Interest: The authors declare that they have no conflict of interests. Financial Disclosure: The authors declare that this study received no financial support.