ARKA KAPAK KAPAK

European Symposium on Urogenital Radiology September 19 – 22, 2013 Istanbul – TURKEY

Pre-Symposium Courses: Obstetric Ultrasound Course ESUR Prostate MRI Course Prostate Ultrasound and Biopsy Course September 18 – 19, 2013 Istanbul - TURKEY, Harbiye Museum & Cultural Centre

“Oncologic Imaging of the Urogenital System” www.esur2013.org “Oncologic Imaging of the Urogenital System” “Oncologic Imaging of the Urogenital System” www.esur2013.org

ORGANIZING SECRETARIAT ABSTRACTS DEKON Congress & Tourism Gayrettepe Mah. Yıldız Posta Cad. Akın Sitesi 1. Blok No: 6 Kat: 1 D: 3 34349 Beşiktaş - Istanbul / TÜRKİYE Tel: +90 212 347 63 00 Fax: +90 212 347 63 63 E-mail: [email protected] Web: www.dekon.com.tr European Society of Urogenital Radiology | www.esur.org ÖN KAPAK İÇİ ARKA KAPAK İÇİ

ESUR 2013 gratefully acknowledges the support of the following sponsors

Main Sponsor

Other Sponsors

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SIE_Skyra_ilan_210x297mm.indd 1 9/2/13 11:16 PM European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY CONTENTS

Welcome 3

Faculty 4

Social Programme 6

General Information 7

Programme Overview 8

Floor Map 18

Abstracts

Members’ Day Sessions 19

Lecture Sessions 29

Workshops 56

Scientific Sessions 92

Posters 124

Author Index 208

1 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

www.esur2013.org 2 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WELCOME TO 20th EUROPEAN SYMPOSIUM ON UROGENITAL RADIOLOGY (ESUR 2013)

Dear Colleagues,

It is an honor and a pleasure for me to invite you to the 20th European Symposium on Urogenital Radiology, ESUR 2013, which will be held on September 19 - 22, 2013 and Courses on Obstetric Ultrasound, Prostate MRI and Prostate Ultrasound and Biopsy that will be given on September 18 – 19, 2013.

Extending to both, Europe and Asia, Istanbul is the only city in the world situated on two continents. It is uniquely surrounded by thousands of years of historical and cultural heritage. Istanbul is not only the geographical meeting point of the continents, but is the true melting pot of cultures and civilizations, both eastern and the western. Located at the crossroads of East and West, Istanbul offers easy air connections to hundreds of cities around the world and is one of the world’s most exciting conference destinations. Its outstanding infrastructure, including modern, luxurious accommodations with conference and exhibition venues makes the city one of the best choices.

The scientific program will provide you with the most advanced knowledge and the cutting edge in urogenital radiology. I would also like to invite you to submit your scientific papers and posters for presentation in scientific sessions. With your help and highly valuable contribution, I am sure the general quality of the discussions will increase tremendously.

I have no doubt this meeting will be a valuable opportunity for all of you in a scientifically enriched environment in perfect harmony with all historical beauties of magnificent Istanbul and Turkish hospitality.

On behalf of the Organizing Committee I am committed to preparing what I hope will be a memorable meeting for you and I hope to have the pleasure of welcoming you to Istanbul.

Cordial Regards,

Ahmet Tuncay Turgut, MD Chairman of ESUR 2013

3 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

ESUR Board Subcommittees

Michel Claudon President Evaluation of Poster Abstracts Harriet Thoeny President-elect Gertraud Heinz-Peer Past President Halil Arslan(TR) Raymond Oyen Secretary/Treasurer Kemal Ödev(TR) Teresa Margarida Cunha Member-at-large Nicolas Grenier(FR) Parvi Ramchandani(USA) Sameh Hanna(EG) Scientific Committee Sami Moussa(UK) Yusuf Öner(TR) Ahmet Tuncay Turgut (TR) Chairman Bernd Hamm (DE) Boris Brkljacic (HR) Evaluation of Scientific Paper Abstracts Gertraud Heinz-Peer (AT) Harriet Thoeny (CH) Andrea Rockall(UK) Henrik Thomsen (DK) Barış Türkbey(USA) Lorenzo Derchi (IT) Boris Brkljacic(HR) Michel Claudon (FR) Jonathan Richenberg(UK) Nicolas Grenier (FR) Mutlu Sağlam(TR) Nigel Cowan (UK) Seung Hyup Kim(KR) Parvati Ramchandani (USA) Vibeke Logager(DK) Sameh Morcos (UK) Sami Moussa (UK) Seung Hyup Kim (KR) Evaluation of Members’ Day Presentations Tarek Eldiasty (EG) Vibeke Logager (DK) Deniz Akata(TR) Vikram Dogra (USA) Gertraud Heinz-Peer(AU) Harriet Thoeny(CH) Michel Claudon(FR) Local Organizing Committee Sami Moussa(UK)

Ahmet Tuncay Turgut - Chairman Alparslan Ünsal Selection of Best Posters Aslan Bilici Baki Yağcı Henrik Thomsen(DK) Cemil Yağcı Marie-France Bellin(FR) Demir Apaydın Mustafa Özmen(TR) Deniz Akata Tarek Eldiasty(EG) Elif Ergun Teresa Margarida Cunha(PT) Ercan Kocakoç Eriz Özden Gökhan Pekindil Selection of Best Scientific Papers Gürsel Savcı Halil Arslan Ercan Kocakoç(TR) İsmail Mihmanlı Jelle Barentsz(NL) Kemal Ödev Jonathan Richenberg(UK) Murat Acar Lorenzo Derchi(IT) Murat Danacı Nicolas Grenier(FR) Mustafa Özmen Raymond Oyen(BE) Mustafa Seçil Rosemarie Forstner(AT) Mutlu Sağlam Sameh Morcos(UK) Süreyya Özbek Vikram Dogra(USA)

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Faculty

Adnan Kabaalioğlu (TR) Jurgen Futterer (NL) Ahmet T. Turgut (TR) Kemal Ödev (TR Alex Kirkham (UK) Krish Gaitonde (USA) Anders Magnusson (SE) Levent Altın (TR Andrea Laghi (IT) Lorenzo Derchi (IT) Andrea Rockall (UK) Luis Marti Bonmati (ES) Ateş Kadıoğlu (TR) Maria Assunta Cova (IT) Atif Zaheer (USA) Marie-France Bellin (FR) Ayşe Erden (TR) Marta Heilbrun (USA) Barış Türkbey (USA) Masoom Haider (USA) Bernd Hamm (DE) Mehmet Ertürk (TR) Bob Djavan (AT) Michael Riccabona (AT) Boris Brkljacic (HR) Michel Claudon (FR) Bülent Tıraş (TR) Michele Bertolotto (IT) Catherine Roy (FR) Mike Notohamiprodjo (DE) Celine Alt (DE) Mithat Haliloğlu (TR) Corrine Balleyguiere (FR) Mohamed Abou El Ghar (EG) Elif Ergun (TR) Mustafa Özmen (TR) Demir Apaydın (TR) Mustafa Seçil (TR) Deniz Akata (TR) Muzaffer Başak (TR) Devrim Akıncı (TR) Nefise Çağla Tarhan (TR) Diana Gaitini (IL) Nevra Elmas (TR) Ercan Kocakoç (TR) Nicolas Grenier (FR) Erdem Canda (TR) Nicolas Papanicolaou (USA) Erhan Akpınar (TR) Nishat Bharwani (UK) Errol Colak (CA) Okan Akhan (TR) Fatih Atuğ (TR) Öner Şanlı (TR) Fatih Kantarcı (TR) Parvati Ramchandani (USA) Filipe Caseiro-Alves (PT) Paul Nikolaidis (USA) Francesco M. Danza (IT) Phil Kenney (USA) Francois Cornud (FR) Pietro Pavlica (IT) Frederika Papadopoulou (GR) Raghu Vikram (USA) Gabriele Masselli (IT) Raj Mohan Paspulati (USA) Geert Villeirs (BE) Rania Farouk El Sayed (EG) Georg Bongartz (CH) Raymond Oyen (BE) George Hadjidekov (BUL) Richard Cohan (USA) Gertraud Heinz-Peer (AT) Rosemarie Forstner (AT) Gökhan Pekindil (TR) Ruhi Onur (TR) Gürsel Savcı (TR) Sadhna Verma (USA) H. Alberto Vargas (USA) Sameh Hanna (EG) Harriet Thoeny (CH) Sameh Morcos (UK) Henrik S. Thomsen (DK) Sami Moussa (UK) Hersh Chandarana (USA) Selma Uysal Ramadan (TR) Hiromu Mori (JP) Seung Hyup Kim (KR) Isaac R. Francis (USA) Süreyya Özbek (TR) Isabelle Thomassin-Naggara (FR) Takehiko Gokan (JP) James Ellis (USA) Tarek Eldiasty (EG) Jarl Jakobsen (NO) Teresa Margarida Cunha (PT) Jean Michel Correas (FR) Ulrich Willi (USA) Jeffrey Newhouse (USA) Valeria Panebianco (IT) Jelle Barentsz (NL) Vibeke Logager (DK) Josephine McHugo (UK) Vikram Dogra (USA) Jochen Walz (NL) Wael Shabana (USA) John Spencer (UK) Wui Chong (USA) Jonathan Richenberg (UK) Yasemin Karadeniz Bilgili (TR) Julian Keanie (UK)

5 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY SOCIAL PROGRAMME

Members’ Dinner Member’s dinner will take place at Baltalimani Shore Palace on September 19, 2013. Istanbul University Baltalimanı Social Facilities formerly known as Baltalimani shore palace has an exquisite view of Bosphorus giving you an unbeatable atmosphere for your dining pleasure.

Serving an up-to-date synthesis of traditional Turkish cuisine, Istanbul University Baltalimanı Social Facilities develops its menus according to the season, procuring only traditional, natural foodstuffs and carefully preserving the classic flavors.

Welcome Reception Welcome Reception will take place at 20 September 2013 at the Backyard of the Congress Venue

Gala Dinner Gala Dinner will take place at Rahmi Koç Museum on 21 September 2013. The Museum is located on the northern shore of Golden Horn, Hasköy neighbourhood of Beyoğlu. It lies on three separate parts of around 27000sqm.

Lengerhane is the first building of the Museum. In 1991, the building was bought and restored by Rahmi M. Koç Museology and Culture Foundation. After a meticulous restoration an underground gallery was added to the original building and in December 1994 the Museum opened its doors for visitors.

This old Ottoman anchor house was founded during the reign of Sultan Ahmet the Third (1703-1730) on the bases of a Byzantium building from the 12th century and now it is considered as a second-tier historical trace. “Lenger” means “anchor and chain”, “hane” means “house”.

www.esur2013.org 6 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY GENERAL INFORMATION

Abbreviations Liability The organizers cannot be held responsible for any MDSS Members’ Day Session personal injury, accident, damage to private property LS Lecture Session or additional expenses incurred as a result of WS Workshop changes of dates, venue, programme or otherwise. SS Scientific Session P Poster Photographing/Recording It is prohibited to take pictures, record or tape any Presenting author underlined presentations or sessions without official permission of the organizers. Badges It is mandatory for all participants to wear their Poster Exhibition badges visibly throughout the meeting as it is the Scientific posters are exhibited in the poster area in entrance ticket to all sessions. In the event of badge Upper Floor Main Foyer. loss, please contact the registration desk. Members’ Day Presentation Award Certificate of Attandance The announcement of award winning paper of the A certificate of attandance will be handed out with Members’ Day Presentations will be made at the your congress documents. Members’ Dinner on 19 September. Poster Prize WIFI The best poster exhibit will be awarded a diploma The internet can be accessed wirelessly. The login during the closing ceremony. Evaluation of the credentials are as below; posters will be based on novelty, accuracy, Wireless Name : ESUR2013 educational value and design. Password : esur2013 Best Scientific Paper Prize Coffee Breaks The best scientific paper will be awarded a Refreshments will be available for registered diploma during the closing ceremony. Evaluation participants and accompanying guests during the of the posters will be based on novelty, accuracy, designed coffee break times. educational value and design. Oral Presentations Lunches A preview centre for viewing and editing your Lunch boxes will be served to all delegates during presentation is located at the Upper Foyer. lunch symposiuma, sponsored by; Speakers are requested to upload their presentations by the break before their session at latest. A member Eigen : Friday 20 September, 12:30 – 13:30 of the staff and audiovisiual technician will assist in Bracco : Saturday 21 September, 12:45 – 13:45 remedying any errors found and will provide a brief explanation of any particular aspects. Conference Language Conference Language is English All PCs and Laptops provided by the venue are supplied with Microsoft PowerPoint 2010. Conference Venue Presentations should be supplied in .ppt or .pptx Harbiye Museum & Cultural Centre format. Please DO NOT bring .pps or .ppsx (Powerpoint show) files. Conference Registration Thursday September 19 (Members’ Day): Accreditation 08:00 – 19:00 Friday September 20: European CME credits (ECMEC) 08:00 – 19:00 Saturday September 21: A total of 18 European CME credits (ECMEC) 08:00 – 19:00 have been awarded by the European Accreditation Sunday September 22: Council for Continuing Education(EACCME). 08:00 – 13:40

7 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY PROGRAMME

Thursday 19 September - Members Day

14:00 - 15:30 Session 1 (Scientific Presentations) 30 Ağustos Meeting Room (Moderators: Michel Claudon, Gertraud Heinz-Peer)

15:30 – 16:00 Coffee Break

16:00 - 17:30 Session 2 (Scientific Presentations) 30 Ağustos Meeting Room (Moderators: Harriet Thoeny, Sami Moussa)

17:30 - 18:00 ESUR Update by ESUR President 30 Ağustos Meeting Room

20:00 Members’ Dinner Announcement of Award Winning Paper of the Members’ Day Presentations (Michel Claudon, ESUR President)

Friday 20 September

08:00 - 18:00 Registration

Poster Exhibition

08:55 - 09:00 Welcome address (Michel Claudon, Ahmet T. Turgut) 30 Ağustos Meeting Room

09:00 - 10:30 Lecture session 1 - Imaging of Renal Tumors 30 Ağustos Meeting Room (Moderators: Isaac R. Francis, Hiromu Mori) 1. Imaging and management of incidental renal masses (Seung Hyup Kim) 2. Role of image guidance in renal sparing management of RCC (Francesco M. Danza) 3. Is it time to develop guidelines for the follow-up of treated RCC? Imaging perspective (Marie France Bellin, Nicolas Grenier) 4. Is it time to develop guidelines for the follow-up of treated RCC? Clinical perspective (Öner Şanlı)

10:30 - 11:00 Coffee Break

11:00 - 12:30 Lecture session 2 - Controversies in Prostate 30 Ağustos Meeting Room Cancer Imaging (Moderators: Jonathan Richenberg, Jelle Barentsz) 1.What does Urologist expect from Uro-Radiologist on detection/staging of PSA detected PCa? (Bob Djavan) 2. Prostate biopsy after MRI: Cognitive fusion with TRUS? MR-guided? TRUS/MRI fusion? (Masoom Haider) (Jurgen Futterer)(Alex Kirkham) 3. Endorectal coil for mpMRI: Is it necessary?:(Barış Turkbey) (Vibeke Logager) (Sadhna Verma)(Francois Cornud) Debate and vote 4. 3T MRI for prostate - is it important? (Valeria Panebianco)(H. Alberto Vargas) 5. MR Spectroscopy - crucial for diagnosis or just a research tool? (Geert Villeirs) (Jelle Barentsz) 6. Panel Discussion (All speakers and the audience)

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12:30 - 13:30 EIGEN Lunch Symposium 30 Ağustos Meeting Room Robotic Targeted Prostate Biopsy, MRI/TRUS Fusion System (Krish Gaitonde,Daniel Margolis, Sadhna Verma)

13:30 - 15:00 Lecture session 3 - Female Genital Tract Tumors 30 Ağustos Meeting Room (Moderators: Teresa Margarida Cunha , Marta Heilbrun) 1. Ovarian cancer: Diagnosis, staging and predicting advanced disease (Deniz Akata) 2. Functional imaging in advanced disease of the uterus and cervix (Corrine Balleyguiere) 3. Challenging female pelvic tumor cases; mistakes I have made-I (Andrea Rockall) 4. Challenging female pelvic tumor cases mistakes I have made-II (Rosemarie Forstner)

15:00 – 15:30 Coffee Break

15:30 - 17:00 Workshops I) Oncologic Imaging of the Female Genital Tract 30 Ağustos Meeting Room (Moderators: John Spencer, Celine Alt) 1 Rare tumors of the uterus (Nishat Bharwani) 2. Rare tumors of the ovary (This could include germ cell tumours and metastases) (Isabelle Thomassin-Naggara) 3. Tumors of the vagina and vulva: The role of imaging in treatment planning and follow- up (Rosemarie Forstner) 4. Patterns of metastatic disease spread in the female pelvis (Atif Zaheer) 5. PET CT in gynecological malignancies - evidence, findings and pitfalls (Raghu Vikram) 6. Complications following treatment of gynaecologic cancers (Çağla Tarhan)

II) Imaging of the Patient with Hematuria İnönü Meeting Room (Moderators: Wael Shabana, Mehmet Ertürk) 1. IVP and US: Role in future? (Julian Keanie) 2. Non-contrast CT and CT urography (Ercan Kocakoç) 3. MR urography (Tarek Eldiasty) 4. Which modality is appropriate for hematuria? Interactive case discussion (Catherine Roy)

III) Interventional Procedures in GU Disorders Barbaros A Meeting Room (Moderators: Devrim Akıncı, Sami Moussa) 1. Renal tumor ablation (Nicolas Grenier) 3. Embolization of male varicocele (Sami Moussa) 3. Intensification of the interaction between Urologists and Interventional Radiologists (Jochen Walz)

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IV) Functional Imaging and Tissue Fevzi Çakmak Meeting Room Characterization of the Urogenital Tract (Moderators: Harriet Thoeny, Bernd Hamm) 1. Role of PET-CT/MR-PET imaging (Raj Paspulati) 2. Elastography (Jean Michel Correas) 3. Renal CT perfusion (Mike Notohamiprodjo) 4. Renal MR perfusion (Hersh Chandarana)

V) Tumor Mimics and Uncommon Tumors of the GU Tract Kocatepe Meeting Room (Moderators: Takehiko Gokan, Ayşe Erden) 1. Uncommon upper urinary tract tumors (Parvi Ramchandani) 2. Uncommon lower urinary tract tumors (Lorenzo Derchi) 3. Pseudotumors (Vikram Dogra) 4. Retroperitoneal tumors (Sameh Hanna)

17:45 - 18:00 Opening Ceremony 30 Ağustos Meeting Room

18:00 Welcome Reception (Backyard of the Congress Venue)

Saturday 21 September

08:30 - 10:00 Lecture session 4 - Imaging of Urothelial Tumors 30 Ağustos Meeting Room (Moderators: Nicolas Grenier, Nevra Elmas) 1. Imaging of urothelial tumors: the urologist’s perspective (Fatih Atuğ) 2. The upper urinary tract urothelial cancer (Mustafa Ozmen) 3. Bladder cancer (Richard Cohan) 4. Post-operative imaging (Vibeke Logager)

10:00 – 10:30 Coffee Break

10:30-11:15 GUERBET Invited Lectures 30 Ağustos Meeting Room

11:15 - 12:45 Lecture Session 5 Combined ESGAR Session Personalized Treatment of Abdominal Tumors: General Principles (Moderators: Michel Claudon, Luis Marti Bonmati) 1. Future developments in imaging of urothelial carcinoma (Maria Cova) 2. Can we differentiate RCC subtypes with imaging (Raymond Oyen) 3. Vascular disorders of the liver: a roadmap for imaging diagnosis (Filipe Caseiro-Alves) 4. MR Imaging biomarkers in rectal cancer (Andrea Laghi)

12:45 - 13:45 Bracco Lunch Symposium 30 Ağustos Meeting Room

www.esur2013.org 10 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

13:45- 14:15 Lecture Session 6 SAR Honorary Lecture 30 Ağustos Meeting Room (Moderators: Ahmet T. Turgut, Michel Claudon) New Horizons in Prostate imaging (Vikram Dogra)

14:15 - 14:20 Honorary Membership Ceremony for Ulrich Willi 30 Ağustos Meeting Room

14:20 - 14:30 Awards for Winning Papers from Members’ Day 30 Ağustos Meeting Room

14:30 - 15:30 Lecture Session 7 Contrast Agents and Safety 30 Ağustos Meeting Room (Moderators: James Ellis, Jarl Jakobsen) 1. Kidney function - eGFR, questionnaire etc. (Georg Bongartz) 2. Contrast media and the kidney (Sameh Morcos) 3. Acute non-renal adverse reactions: Is it always an adverse reaction? (Marie-France Bellin) 4. Nephrogenic systemic fibrosis - 7 years on (Henrik S. Thomsen)

15:30 – 16:00 Coffee Break

16:00- 17:30 Workshops I) Adrenal Tumors 30 Ağustos Meeting Room (Moderators: Nick Papanikolau, Gürsel Savcı) 1. Comprehensive imaging algorithm of the incidental adrenal masses (Paul Nikolaidis) 2. The role of new imaging techniques- PET-CT and DWI in adrenal imaging (Gertraud Heinz-Peer) 3. Malignant adrenal tumors and treatment options (Phil Kenney)

II) Renal Vascular Imaging İnönü Meeting Room (Moderators: Süreyya Özbek, Anders Magnusson) 1. Renal doppler ultrasound (Diana Gaitini) 2. CTA and MRA/Evaluation of renal artery stenosis (Ruhi Onur) 3. Interventional procedures for hypertension (Boris Brkljacic) 4. Preoperative imaging assessment of renal donors and recipients (Errol Colak) 5. Vascular complications of the transplanted kidney (Michel Claudon)

III) Male Genital Tract Tumors Barbaros A Meeting Room (Moderators: Raymond Oyen, Lorenzo Derchi) 1. Incidentally detected testicular tumors (Wui Chong) 2. Extratesticular scrotal tumors (Mustafa Seçil) 3. Penile lumps (Michele Bertolotto) 4. Testicular sparing surgery (Erdem Canda)

IV) Imaging of Infectious Diseases of GU tract Kocatepe Meeting Room (Moderators: Adnan Kabaalioğlu, Tarek Eldiasty) 1. Hydatid disease (Okan Akhan) 2. Non-hydatid parasitic infections (Mohamed Abou El Ghar) 3. Acute and chronic pyelonephritis (Jeffrey Newhouse) 4. Infectious diseases of the male and female genital tract (Gabriele Masselli)

11 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

V) Infertility Fevzi Çakmak Meeting Room (Moderators: Parvati Ramchandani, Jo McHugo) 1. How to manage infertile couple: Gynaecologist’s perspective (Bülent Tıraş) 2. Role of imaging in female infertility (Francesco M. Danza) 3. How to manage infertile couple: Urologist’s perspective (Ateş Kadıoğlu) 4. Role of imaging in male infertility (Pietro Pavlica)

Sunday 22 September

08:00 - 09:00 Scientific Paper Presentations I 30 Ağustos Meeting Room Gynecological Tumors Moderators: F. Demir Apaydın, Rania Farouk El Sayed

08:00 – 08:09 SS1.01 - Prognostic values of pretreatment SUV max and ADC mean in cervical cancer patients treated with definitive chemoradiotherapy Gürcan Erbay 08:09 – 08:18 SS1.02 - ADC mean is a predictive marker for metabolic response in cervical cancer patients treated with definitive chemoradiotherapy Gürcan Erbay 08:18 – 08:27 SS1.03 - Added value of diffusion-weighted MR imaging in the differential diagnosis of benign and malignant solid components of adnexal lesions Sung Eun Rha 08:27 – 08:36 SS1.04 - Uterine cervical malignancy: Diagnostic accuracy of MRI with histopathologic correlation Pelin Demir 08:36 – 08:45 SS1.05 - Predicting the tumor response with diffusion-weighted imaging in cervical cancer patients treated with definitive chemoradiotherapy Gürcan Erbay 08:45 – 08:54 SS1.06 - Review of borderline ovarian tumors; in Korean Hospital Kyoung Ah Kim

08:00 - 09:15 Scientific Paper Presentations II İnönü Meeting Room Prostate Cancer Imaging-I Moderators: Yasemin Karadeniz Bilgili, Elif Ergun

08:00 – 08:09 SS2.01 - High b-value diffusion weighted MR imaging at 3 T for tumor detection and discrimination of aggressiveness of prostate cancer Tsutomu Tamada

08:09 – 08:18 SS2.02 - Evaluation of diffusion kurtosis imaging in patients with prostate cancer Matthias Roethke

08:18 – 08:27 SS2.03 - Identification of apparent-diffusion-coefficient (ADC) cut-off-values for the detection of nodal metastasis in high-risk prostate cancer patients: Implication for clinical practice Marc Regier

08:27 – 08:36 SS2.04 - Evaluation of the PI-RADS classification in patients with negative systematic pre- biopsies of the prostate and ongoing cancer suspicion Daniel Junker

08:36 – 08:45 SS2.05 - Risk stratification of possible prostate cancer using prebiopsy MRI: A multisite study Wolfgang Picker

08:45 – 08:54 SS2.06 - Preoperative MRI prostate for diagnosis of T3 prostate cancer: MRI with pathological correlation Harpreet Lyall

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08:00 - 09:15 Scientific Paper Presentations III Fevzi Çakmak Meeting Room Renal Tumors Moderators: Muzaffer Başak, Andrea Rockall

08:00 – 08:09 SS3.01 - Role of diffusion weighted sequence and apparent diffusion coefficient in characterization of renal masses in patients with medical nephropathy Ahmad Afifi -Hafez

08:09 – 08:18 SS3.02 - Differentiation between renal cell carcinoma subtypes using diffusion weighted sequence Ahmad Afifi -Hafez

08:27 – 08:36 SS3.03 - Utility of MR imaging for prediction of nuclear grade in clear cell renal cell carcinoma Akira Yamamoto

08:36 – 08:45 SS3.04 - Differentiation of benign and malignant renal lesions with interface types at MRI Fatma Kulali

08:45 – 08:54 SS3.05 - Computed tomography in the diagnosis of kidney malignant lymphoma Roman Titorenko

08:54 – 09:03 SS3.06 - Radiological features of unusual renal masses Musa Atay

09:03 – 09:12 SS3.07 - Subtype discrimination of renal cell cancer by using diffusion images Hale Çolakoğlu Er

08:00 - 09:15 Scientific Paper Presentations IV Kocatepe Meeting Room Interventional Procedures & Minimally Invasive Therapies Moderators: Kemal Ödev, Tarek Eldiasty

08:00 – 08:09 SS4.01 - Fluoroscopically guided removal of ‘lost thread’ IUCDs: A novel technique Hugh Harvey

08:09 – 08:18 SS4.02 - Ultrasound guided urogenital interventions: procedural techniques and clinical usefulness Cherian George

08:18 – 08:27 SS4.03 - Pyonephrosis - an overdiagnosed condition? Karin Gregertsen

08:27 – 08:36 SS4.04 - Radiofrequency ablation (RFA) of renal cell carcinoma (RCC): Experience in 200 tumours Amjad Mohammed

08:36 – 08:45 SS4.05 - The midterm outcome of image guided percutaneous cryoablation (CRYO) of renal tumours Naeem Jagirdar

08:45 – 09:54 SS4.06 - Renal cryoablation: Does tumour position effect technical and oncological outcome? Alexander J King

13 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

08:54 – 09:03 SS4.07 - Image-guided thermal ablation of adrenal tumours – a single centre experience Alexander J King

09:03 – 09:12 SS4.08 - The effect on renal function following image guided radiofrequency ablation (RFA) of renal tumours Amjad Mohammed

09:15 - 09:30 Coffee Break

09:30 - 10:35 Scientific Paper Presentations V 30 Ağustos Meeting Room Fetal Imaging Moderators: Selma Uysal Ramadan, George Hadjidekov

09:30 – 09:39 SS5.01 - Fetal biometry in polyhydramnios: Does femur length fall behind? Özlem Ünal

09:39 – 09:48 SS5.02 - Cavum septum pellucidum et vergae frequency in normal fetusus in third trimester Özlem Ünal

09:48 – 09:57 SS5.03 - Fetal magnetic resonance imaging of genitourinary pathologies Bahattin Özkul

09:57 – 10:06 SS5.04 - Diagnostic value of fetal MRI in evaluating fetal urinary anomalies Noha Behairy

10:06 – 10:15 SS5.05 - Role of MRI in the diagnosis of fetal anomalies Betül Şimşek

10:15 – 10:24 SS5.06 - Choroid plexus separation in fetuses without ventriculomegaly: Postnatal outcome Aslı Tanrıvermiş Sayıt

10:24 – 10:33 SS5.07 - Diameter differences in fetal umbilical arteries affect doppler findings of the common iliac arteries Aslı Tanrıvermiş Sayıt

09:30 - 10:35 Scientific Paper Presentations VI İnönü Meeting Room Stone Disease and Male Genital System Disorders Moderators: Erhan Akpınar, Pietro Pavlica

09:30 – 09:39 SS6.01 - Impact of 4th generation iterative reconstruction techniques on image quality in ultralow-dose MDCT for suspected urolithiasis Marc Regier

09:39 – 09:48 SS6.02 - Low-dose dual-source dual-energy CT for urolithiasis: Feasibility study Michele Pansini

09:48 – 09:57 SS6.03 - Impact of ureteral jet flow on urinary tract stone formation Canan Altay

09:57 – 10:06 SS6.04 - Alternative and incidental findings on unhanced MDCT in patients with flank pain: Prevalence and characteristics Selcuk Parlak

10:06 – 10:15 SS6.05 - X-ray endovascular treatments of vascular erectile dysfunction Oleg Zhukov

www.esur2013.org 14 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

10:15 – 10:24 SS6.06 - Magnetic resinance imaging and diffusion weighted magnetic resonance imaging as a problem solving imaging modality in different testicular lesions Ahmad Afifi -Hafez

10:24 – 10:33 SS6.07 - Multimodality imaging of spermatic cord absess Mehmet İncedayı

09:30 - 10:45 Scientific Paper Presentations VII Barbaros A Meeting Room Prostate Cancer Imaging-II Moderators: Gökhan Pekindil, Vibeke Logager

09:30 – 09:39 SS7.01 - Impact of pelvic biometric measurements, visceral and subcutaneous adipose tissue areas on trifecta outcomes after open radical prostatectomy Naciye Sinem Gezer

09:39 – 09:48 SS7.02 - Efficacy of the European Society of Uroradiology’s PI-RADS classification system in pre-biopsy prostate MRI Chirag Patel

09:48 – 09:57 SS7.03 - First results of MRI-targeted TRUS-guided transperineal fusion biopsies to restratify prostate cancer patients under active surveillance Timur Kuru

09:57 – 10:06 SS7.04 - PI-RADS and Gleason scores: are they associated? Experience in 244 operated patients Giuseppe Petralia

10:06 – 10:15 SS7.05 - The predictive value of apparent diffusion coefficient changes in prostate cancer patients treated with radiotherapy Gürcan Erbay

10:15 – 10:24 SS7.06 - The correlation of pharmacokinetic parameters of dynamic contrast-enhanced MR imaging in tumors and normal prostate gland Gürcan Erbay

10:24 – 10:33 SS7.07 - Validation of the simplified IVIM approximation in prostate cancer imaging Salvatore Francesco Carbone

10:33 – 10:42 SS7.08 - Evolution of MRI signal intensities and ADC values in prostate gland and prostate cancer post non thermal irreversible electroporation Michal Studniarek

09:30 - 10:45 Scientific Paper Presentations VIII Kocatepe Meeting Room Ultrasound Imaging Moderators: Fatih Kantarcı, Diana Gaitini

09:30 – 09:39 SS8.01 - Real-time sonographic depiction of twisted vascular pedicle in ovarian torsion Eun Ju Lee

09:39 – 09:48 SS8.02 - Sonographic incidence and findings of renal cyst Hacer Fırat

09:48 – 09:57 SS8.03 - The role of transperineal ultrasound in the evaluation of females with urinary incontinence compared to urodynamic studies Manal Wahba

15 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

09:57 – 10:06 SS8.04 - Renal duplication and renal size relationship in asymptomatic adults measured by ultrasound Evren Üstüner

10:06 – 10:15 SS8.05 - Klinefelter disease: Sonographic testis findings with hormonal and pathologic correlations Laurence Rocher

10:15 – 10:24 SS8.06 - Contribution of sonoelastography in diagnosis of polycystic ovary syndrome Ayşe Nur Şirin Özcan

10:24 – 10:33 SS8.07 - Real time elastosonographic evaluation of renal transplants in correlation with clinical prognostic parameters: preliminary results İdil Güneş Tatar

10:33 – 10:42 SS8.08 - Real-time elastography in diagnostics of urology disease Oleg Zhukov

09:30 - 10:25 Scientific Paper Presentations IX Fevzi Çakmak Meeting Room Miscellaneous Moderators: Moderators: Levent Altın, Raj Mohan Paspulati

09:30 – 09:39 SS9.01 - The role of diffusion weighted MRI for evaluation perianal fistulae Hüseyin Yetiş

09:39 – 09:48 SS9.02 - NSsaFE study: observational study on the incidence of nephrogenic systemic fibrosis in renal impaired patients following gadoteric acid administration Bart Maes

09:48 – 09:57 SS9.03 - The value of diffusion-weighted imaging in endometriotic cysts Pelin Zeynep Bekin Sarıkaya

09:57 – 10:06 SS9.04 - Serum creatinine measurements: Evaluation of a questionnaire according to the ESUR guidelines Georg Bongartz 10:06 – 10:15 SS9.05 - Computed Tomography staging of bladder cancer: What are the chest findings? Ferekh Salim

10:15 – 10:24 SS9.06 - Evaluation of the left renal vein variations, the inferior vena cava variations and renal anomalies by magnetic resonance imaging Ümit Yaşar Ayaz

10:45 – 12:15 Lecture session 8 Pediatric Urogenital Imaging 30 Ağustos Meeting Room (Moderators: Michael Riccabona, Ulrich Willi) 1. Pitfalls in imaging urogenital masses during childhood: case based demonstration of common problems - how to image, who they look, what to look for, and differences from common approaches in adults (Ulrich Willi) 2. Impact of recommendations and guideline on clinical practise – does it matter at all? Results of an European questionnaire (Michael Riccabona) 3. Contrast enhanced US of the childs’ urinary tract revisited (Frederika Papadopoulou, K. Ntoulia, K. Darge, M. Riccabona) 4. News from the paediatric uroradiology task force (Michael Riccabona) 5. Paediatric genital & pelvic tumours: imaging approach, differential diagnosis, typical examples (Mithat Haliloğlu)

www.esur2013.org 16 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

12:15 - 13:15 Film Interpretation Session 30 Ağustos Meeting Room (Moderators: Lorenzo Derchi, Michel Claudon)

13:15 - 13:30 Award presentation: Best Scientific Paper and Poster 30 Ağustos Meeting Room

13:30 - 13:40 Closing Remarks 30 Ağustos Meeting Room

17 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY FLOOR PLAN

ESUR BARBAROS A SECRETARIAT MEETING ROOM

UPPER FLOOR PLAN İNÖNÜ MEETING ROOM

FEVZİ ÇAKMAK MEETING ROOM

30 AĞUSTOS MEETING ROOM

KOCATEPE MEETING ROOM

www.esur2013.org 18 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY ABSTRACTS

Members’ Day

MDSS01 REVIEW OF COMMON GU-RELATED ERRORS DURING INTERPRETATION OF CROSS-SECTIONAL IMAGING Kielar A. 1, Ritchie H. 1, O’Sullivan J. 1, McInnes M. 1 University of Ottawa Radiology Ottawa-Canada 1

Objective: Review common types and locations of GU errors.

Methods: We created a semi-automated, email-based method of documenting errors in our radiology department. QUIP (Quality Initiative Program) will be described in more detail. We reviewed all QUIPs from January 2010-June 2012, organizing errors by body part. GU system includes: kidneys, ureters & bladder, prostate, testicles and adrenals. We classified errors by type: false-positive, false- negative, satisfaction-of-search, cognitive and communication.

Results: Out of 451 QUIPs sent to abdominal subspecialty radiologists, 75 were GU errors (16.7%). This was second only to MSK-related errors (spine, pelvis, femurs etc.) accounting for 18.2%. Small/large bowel accounted for 14.9% and liver accounted for 12.8 % of errors. 50/75 GU errors (66.7%) were related to kidneys, 14 (18.7%) related to ureters/ bladder and 8 (10.7%) from adrenals.

There were 107 types of errors (some had > 1 type). False negative errors accounted for 41/107 (38%). Satisfaction-of-search, a type of false-negative error accounted for 29 (27%). There were 10 false-positive and 21 cognitive errors. Out of 50 errors related to kidneys, 54% were false negative errors. Small, solid renal masses and GU calculi were the most common false-negative errors.

Conclusions: When interpreting cross-sectional imaging, the GU system is associated with a number of false negative. Being aware of this and focusing on the GU system during review (with use of standardized reporting template) may reduce these errors in the future.

MDSS02 DEVELOPMENT OF A PROGNOSTIC, IMAGING-INCLUSIVE MODEL FOR IMPROVED PREDICTION OF DISEASE-FREE SURVIVAL IN PATIENTS WITH RENAL CELL CARCINOMA Karlo C. 1 Memorial Sloan Kettering Cancer Center Radiology New York-United States 1

Objectives: (1) To develop a prognostic model for predicting disease-free survival after nephrectomy for all types and stages of RCC that incorporates demographic, clinical, histopathological and survival data as well as imaging data from CT and MRI. (2) To demonstrate the incremental value of CT and MRI data for predicting disease-free survival, when incorporated in such a model.

Material and Methods: The demographic, clinical, histopathological and survival data of >2,500 RCC patients who underwent partial or total nephrectomy is available through the institution’s electronic medical records system. Their CT and/or MRI data is available through the institution’s PACS. Two radiologists will independently review all available CT and MRI studies and assess all tumors for the following features: size; contour; enhancement degrees and patterns; presence of necrosis; location in relation to the renal hilum; renal vein invasion; perinephric fat invasion; collecting system invasion; calcifications; and tumor growth pattern. Available histopathological data includes size, stage, and nuclear grade of RCC; invasion of the renal vein or its segmental branches, invasion of the renal hilar fat, invasion of the collecting system and invasion of the perinephric fat. We will model disease-free, RCC-specific survival with Cox regression analyses, and we will evaluate the significance of each predictor using competing risks analyses. Furthermore, we will assess the incremental value of CT data and (separately) MRI data for improving the prediction of disease-free survival. The computational model developed will be made publicly available as an online nomogram.

19 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS03 APPARENT DIFFUSION COEFFICIENT VALUES OF NORMAL TESTIS AND VARIATIONS Tsili A. 1, Ntorkou A. 1, Giannakis D. 2, Tsampalas S. 2, Sofikitis N. 2, Argyropoulou M. 1 Medical School-University of Ioannina Clinical Radiology Ioannina-Greece 1 Medical School-University of Ioannina Urology Ioannina-Greece 2

Objective: To determine the apparent diffusion coefficient (ADC) values of normal testis and assess the magnitude of variations with age.

Method: Age-related changes in ADC values of normal testicular parenchyma were investigated in 71 testes from 53 men aged 20-39 years (group 1), 67 testes from 43 men aged 40-69 years (group 2) and 9 testicular units from 6 men older than 70 years old (group 3). Diffusion-weighted imaging (DWI) was performed along the axial plane, using a single shot, multi-slice spin-echo planar diffusion pulse sequence and b-values of 0 and 900 sec mm-2. The mean and standard deviation of the ADC values of normal testicular parenchyma were calculated for each age group separately. Analysis of variance (ANOVA) followed by post hoc analysis (Dunnett T3) was used for statistical purposes.

Results: The ADC values (x 10-3 mm2 s-1) of normal testis were different between the age groups (group 1: 1.08±0.13; group 2: 1.15±0.15; group 3: 1.31±0.22). ANOVA revealed differences of mean ADC between age groups (F=11.391, p < 0.001). Post hoc analysis showed significant differences between groups 1, 2 (p = 0.008) and 1, 3 (p = 0.043), but not between 2, 3 (p = 0.197).<

Conclusion: ADC values of normal testis increase with advancing age.

MDSS04 MODEL BASED ITERATIVE RECONSTRUCTION-LOW DOSE ABDOMINAL CT FOR DETECTION OF URINARY TRACT STONES: INITIAL EXPERIENCE Botsikas D. 1, Stefanelli S. 1, Boudabbous S. 1, Becker C. 1, Montet X. 1 Geneva University Hospital Radiology Geneva-Switzerland 1

Purpose: To study the added benefit of second generation model based iterative reconstructions (MBIR) on low-dose abdominal CT for the detection of urinary tract stones compared to first generation of iterative reconstruction (ASIR).

Materials and methods: Fifty-three consecutive patients (35 men-18 women) , mean age 52.3 ± 16.6 y underwent unenhanced low-dose abdominal CT for detection or follow-up of urinary tract stones from August to November 2012. Ureteral definition was evaluated subjectively by two blinded readers who graded it in a scale from 1(excellent definition) to 4(=not distinguishable) and objectively by calculating contrast to noise ratio(CNR) for soft tissue-fat on a standard 40%ASIR-FBP reconstruction and on the corresponding MBIR series. Stone position, maximal density and diameter on the axial plane were also evaluated on both series.

Results: There was a substantial agreement between readers for subjective evaluation of ureteral definition (k=0.872). The ureteral definition was significantly better for the MBIR series (mean score=1.998+/-0.839) compared to the ASIR/FBP series (median score=2.536+/-0.799) (p<0.0001). The CNR was significantly better on the MBIR (=17.82+/-4.84) compared to ASIR/FBP(=6.066+/-1.985) (p<0.0001). Sixty-nine stones were found in total. Their maximal density measured from MBIR was significantly higher (754.4+/-376.5) than that measured from FBP/ASIR (559.4+/-352.4) (p<0.0001). Stones size was over evaluated on MBIR (mean diameter=4.91+/-2.61mm) compared to FBP/ASIR(=4.52+/-2.63mm) (p<0.0001).

Conclusion: MBIR reconstruction of low dose abdominal CT can offer significantly better ureteral definition and its systematic use is recommended. Though, it has the tendency to systematically over evaluate the stones densities and sizes compared with ASIR/FBP.

www.esur2013.org 20 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS05 THE ROLE OF INTRA-OPERATIVE ULTRASOUND IN ROBOT ASSISTED SURGERY OF RENAL TUMORS Kismali E. 1, Gurer E. 2, Turna B. 2 Ege University Faculty Of Medicine Radiology Izmir-Turkey 1 Ege University Faculty Of Medicine Urology Izmir-Turkey 2

Objective:To determine the intra-operative laparoscopic ultrasound(ILUS)imaging as an accurate tool during robot assisted surgery of renal tumors.

Method: 5 patients who had undergone robot assisted laparoscopic partial nephrectomy were included in this study. Partial nephrectomy was performed by “da Vinci” Robot Assisted Surgery System . ILUS was performed by Siemens Sonoline Omnia device with 4-6 MHz flexible tip surgical probe. In exploration and the resection, the radiologist had demonstrated the renal sinus by Doppler ultrasound according to the operator’s needs. The ultrasound real time video stream merged to the corner of 3D stereoscopic screen at the operator’s console on site.

Results: ILUS was performed in 2 patients of 5 patients who were undergone partial laparoscopic nephrectomy with robot assisted surgery. None of the patients have residual tumor after surgery and no recurrence after 6 months. Total surgery time was under 2 hours and no hemorrhagic complication was occurred.

Conclusion:There is a recognizable increase in the incidence of renal cell carcinoma and a parallel rise in its surgical management. Both conventional and robot assisted laparoscopic renal surgery, the surgeon needs additional information to compensate loss of tactility. ILUS allows visual information by showing the deep tissues to navigate resection procedure in safe. Through the visualization of perirenal tissues, renal vessels and collecting system, ILUS may change surgical approaches. Robot assisted surgery is preferred when the tumor placed posteriorly and close to renal hilus while visualization of deep hilus structures become more important and ILUS can improve the surgical comfort reducing the time safely.

MDSS06 DYNAMIC CONTRAST-ENHANCED MR IMAGING OF THE ENDOMETRIAL CANCER: OPTIMIZING IMAGING DELAY FOR APPROPRIATE TUMOR-MYOMETRIUM CONTRAST Moon M. 1, Sung C. 1, Lee H. 2, Cho J. 3, Kim S. 3 SMG-SNU Boramae Medical Center, Seoul National University College of Medicine Radiology Seoul- Korea, South 1 Seoul National University Bundang Hospital, Seoul National University College of Medicine Radiology Seoul-Korea, South 2 Seoul National University College of Medicine, and the Institute of Radiation Medicine Radiology Seoul-Korea, South 3

Objective: To investigate the optimal imaging delays of dynamic contrast-enhanced MR imaging for appropriate tumor-myometrium contrast in women with endometrial cancer.

Method:This prospective single-institution study was approved by the institutional review board and informed consent was obtained from the participants. Thirty-five women (mean age, 54 years; age range, 29-66 years) performed fat saturated three dimensional fast field echo T1-weighted imaging with a temporal resolution of 25-40 seconds as a standard part of preoperative MR evaluation for endometrial cancer. Signal intensity difference ratios between the myometrium and the endometrial cancer, calculated from time-signal intensity data, were used to investigate the optimal imaging delays of dynamic contrast-enhanced MR imaging by using single changepoint analysis.

Results: The optimal imaging delay time to depict appropriate tumor-myometrium contrast ranged from 31.7 seconds to 268.1 seconds. The median imaging delay time was 91.3 seconds with interquartile range of 46.2 seconds to 119.5 seconds. Median signal intensity difference ratio between the myometrium and the endometrial cancer was 0.03 with interquartile range of -0.01 to 0.06 on the precontrast MR imaging and 0.20 with interquartile range of 0.15 to 0.25 on the postcontrast MR imaging.

Conclusion: The imaging delay of 90 seconds or around after initiating contrast material injection may be optimal to obtain appropriate tumor-myometrium contrast in women with endometrial cancer.

21 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS07 MAGNETIC RESONANCE IMAGING AND PHOSPHOR-SPECTROSCOPY OF PROSTATE CANCER AT 7 TESLA Vos E. 1, Lagemaat M. 1, Maas M. 1, van Uden M. 1, Orzada S. 2, Bitz A. 2, Scheenen T. 1 Radboud University Nijmegen Medical Centre Radiology Nijmegen-The Netherlands 1 Erwin L. Hahn Institute for Magnetic Resonance Imaging, University Duisburg-Essen Radiology Essen-Germany 2

Objective: Ultra-high field MRI may have future advantages for imaging of prostate cancer (PCa) by its increased signal-to-noise ratio, which can be traded for a higher resolution or a faster examination. Because of the higher spectral resolution, other metabolites can be visualized than at lower field strengths. We present the first results of T2-weighted imaging (T2wi) and Phosphor-spectroscopy (31P-MRSI) in patients at 7 Tesla (T).

Methods: Eighteen patients with biopsy-proven PCa and a clinical 3T-MRI exam were included. T2wi was performed on a 7T whole-body MR-system using an 8-channel transmit/receive external body array coil. 3D 31P-MRSI was performed with the external body array coil in combination with a 31P transmit/receive endorectal coil. T2w images were directly compared to 3T images. Spectroscopy voxels in cancer and non-cancer tissue were selected and metabolite ratios were compared to each other.

Results: All patients completed the protocol without adverse events, with a shorter acquisition time for T2wi at 7T (1:53 min versus 4:21 min at 3T). Despite some differences in appearance of image contrast, PCa could be detected on T2w images at 7T. For 31P-MRSI, significant differences were found in metabolite ratios between cancer and non-cancer tissue (lower [phosphoetanolamine/ total phospho-ester metabolites] and lower [inorganic phosphate/γATP], with p=0.02 and p<0.01 respectively).

Conclusion: MRI and 31P-MRSI of PCa patients is feasible at 7T. Anatomical structures and PCa are visible and significant differences in phosphor metabolite ratios were found between PCa and non-cancer tissue. Therefore, MRI and 31P-MRSI at 7T have potential for the detection of PCa.

MDSS08 VALIDITY OF A TRIPLE-BOLUS MULTIDETECTOR COMPUTED TOMOGRAPHY UROGRAPHY PROTOCOL IN DETECTING RENAL AND UROTHELIAL MALIGNANCY. Vanhooymissen I. 1, Atzei R. 1, Burgers P. 1, Dwarkasing R. 1, Willemssen F. 1 Erasmus MC Radiology Leiden-The Netherlands 1

Objective: To evaluate the accuracy of a one phase triple-bolus multidetector CT Urography protocol in the detection of renal and urinary tract malignancy.

Method: Our cohort follow-up study entailed 1472 consecutive CT Urography examinations (1361 patients), performed between June 2007 and August 2010. CT protocol included low-dose unenhanced phase and triple-bolus contrast phase (Visipaque 320 mgI/ml, GE Healthcare Inc.). First bolus 30ml (2ml/s) with delay of 7 minutes, followed by second bolus of 50ml (1.5ml/s), delay 20s, and third bolus of 65ml (3ml/s). Imaging was acquired immediately after the last bolus. Presence and grade of haematuria were assessed. Histological proven malignancy was defined as reference standard. Malignancy was classified into renal-, upper urinary tract-, and bladder lesions. Prevalence, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

Results: Prevalence of malignancy was 11.8% (174/1472), including 108 UCC (62%), 47 RCC (28%) and 19 (10%) other diagnosis. 134/174 (77%) malignancies were detected by CT. Of the remaining 40 malignancies, 35 (88%) were UCC of the bladder, all detected by cystoscopy. Haematuria was present in 96/174 (55%) malignancies (14 microscopic, 64 macroscopic, 15 unspecified). Sensitivity was 77 % (134/174), specificity 96 % (1248/1298), PPV of 73 % (134/184) and NPV of 97 % (1248/1288), in detecting urothelial and renal malignancies. Combined sensitivity of CT and cystoscopy was 97% (169/174).

Conclusion: Triple-bolus CT Urography is an excellent imaging technique for the detection of renal- and upper urinary tract cancer. For diagnosing bladder carcinoma, additional cystoscopy remains mandatory.

www.esur2013.org 22 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS09 IS OUR CTU PROTOCOL INCLUDING UNENHANCED, CORTICOMEDULLARY AND EXCRETORY PHASES AS GOOD AS CYSTOSCOPY IN DETECTING BLADDER TUMOURS Helenius M. 1, Brekkan E. 2, Dahlman P. 1, Magnusson A. 1 Uppsala Akademiska Hospital Radiology Uppsala-Sweden 1 Uppsala Akademiska Hospital Urology Uppsala- Sweden 2

Objective: At our institution a CTU protocol including unenhanced, corticomedullary and excretory phases is used when examining patients with gross hematuria. The entire urinary tract is examined in all three phases. The purpose of this study was to evaluate our CTU protocol in the ability to detect bladder tumours and to compare CTU and cystoscopy results.

Method:All patients with gross hematuria referred for a CTU during a three year period were recruited. Patients’ medical records were reviewed to find the cystoscopy results and the patients’ final diagnosis. The CTU examination reports were studied.

Results: Four hundred and eighty eight patients were included and 54 patients were diagnosed with bladder tumour. In 48 patients (89%) the bladder tumour was described in the CTU report. In five patients the CTU examination report was false positive. Sensitivity in finding bladder tumour with our CTU protocol was 0.89, specificity 0.99, positive predictive value 0.91 and negative predictive value 0.99. Cystoscopy found bladder tumour in 48 patients (89%) and in one patient the cystoscopy findings were false positive. Cystoscopy showed a sensitivity of 0.89, a specificity of 1.0, a positive predictive value of 0.98 and a negative predictive value of 0.99.

Conclusion: Sensitivity and specificity in finding bladder tumours using our protocol were high and comparable to results in other studies using the excretory phase when assessing the bladder. Hence, our protocol can be used to assess the bladder and in patients with normal CTU findings a cystoscopy might be unnecessary.

MDSS10 P.A.D.U.A. SCORING AS A RADIOLOGIST Alt C. 1, Kuru T. 2, Teber D. 2, Hallscheidt P. 3 University Hospital Heidelberg Diagnostic and Interventional Radiology Heidelberg-Germany 1 University Hospital Heidelberg Urology Heidelberg-Germany 2 Radiology Darmstadt-Germany 3

Objective: Evaluation of the P.A.D.U.A. scoring system from a radiological point of view

Method: Retrospective study, evaluating CT scans and MR Imaging which led to the indication of nephron sparing surgery (NSS) in 2011 in our hospital using the validated P.A.D.U.A. scoring system (location to polar line, exophytic rate, infiltration of renal rim, renal sinus or urinary collecting system, size, and face). In total, 48 patients could be included (34 CTs, 27 MRIs). Evaluation was performed by two radiologists independently. The results were compared to intraoperative findings and the interobserver reliability was evaluated. For statistical analysis, Cohen’s kappa coefficient and the rate of total agreement were calculated.

Results:The rate of total agreement of both readers regarding CT to intraoperative scoring ranged from 62 to 88% for reader 1 and from 65 to 88% for reader 2, regarding MRI from 56 to 85% for reader 1 and from 67 to 89% for reader 2, respectively. Interobserver reliability regarding CT ranged from 79 to 97% and regarding MRI from 67 to 89%. Best results could be noted for evaluation of renal rim, UCS and size regarding CT and for renal rim, renal sinus, UCS and size regarding MRI. The worst interobserver reliability could be noted for longitudinal polar location with 79% and 67% regarding CT and MRI, respectively.

Conclusion: P.A.D.U.A. scoring system is a promising method for pretherapeutic evaluation of renal masses, but interobserver reliability showed better results than agreement to intraoperative scoring, which led to the presumption, that the score maybe need some simplification to reach better agreement.

23 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS11 3T MR-IMAGING OF PRIMARY VULVAR CANCER Alt C. 1, Brocker K. 2, Schlemmer H. 3, Hallscheidt P. 4 University Hospital Heidelberg Diagnostic and Interventional Radiology Heidelberg-Germany 1 University Hospital Heidelberg Obstetrics and Gynecology Heidelberg-Germany 2 German Cancer Research Center Radiology Heidelberg-Germany 3 Radiology Darmstadt-Germany 4

Objective: Accuracy of local tumor staging of primary vulvar cancer with dynamic contrast enhanced sequences and diffusion weighted imaging.

Method: 30 patients with primary vulvar cancer were examined at a 3T scanner in this prospective study for local tumor staging including lymph node status using T2w tse sequences in sagittal and transversal plane, diffusion weighted imaging in transversal plane and dynamic contrast enhanced T1w tse sequence with fat saturation in transversal plane. The study proposal was approved by the local ethics committee and all patients gave written informed consent.

Results: Until now, 24 patients underwent primary surgery and could be included in the study. Histopathological T-staging for vulvar cancer was T1a in 4 patients, T1b in 18 patients, T2 and T3 in one patient each. Histopathological N-staging was N0 in 19 patients, N1b in one patient, N2c in 3 patients and N3 in one patient. Total agreement of MRI evaluation to histopathology was 75% (18/24) for T-staging and 88 % (21/24) for N-staging. MRI over- and understaged 3 times each in T-staging, missed one lymph node affection and evaluated 2 times lymph node affection, histopathologically not proven.

Conclusion: Staging of primary vulvar cancer with functional 3T MRI showed good results for T-staging and very good results for N-staging compared to histopathology.

MDSS12 FOLLOW-UP OF SUPERFICIAL URINARY BLADDER CARCINOMA AFTER TRANSURETHRAL RESECTION: DOES DIFFUSION WEIGHTED MRI HAVE A ROLE? Abou El-Ghar M. 1, El-Assmy A. 2, Refaie H. 1, Mosbah A. 2, El-Diasty T. 1 Urology & Nephrology center-Mansoura university Radiology Mansoura-Egypt 1 Urology & Nephrology center-Mansoura university Urology Mansoura- 2

Aim of the work: To study the feasibility of using diffusion-weighted (DW) magnetic resonance imaging (MRI) in bladder cancer follow-up after TUR.

Materials and methods: Between January to December 2011, 47 patients with history of TUR of superficial bladder carcinoma who were admitted at our center for follow-up cystoscopy were prospectively included in this study. Before cystoscopy, DW MRI was performed and the apparent diffusion coefficient (ADC) value was measured in a circular region of interest within the carcinoma and normal bladder wall. Two radiologists, who were blinded to the results of cystoscopy, independently interpreted the DW images. A comparison of imaging findings with the results of cystoscopy was performed using McNemar test.

Results: In our 47 patients, cystoscopy identified 34 bladder lesions in 24 patients and in the reaming 23 the bladder looked normal. In 24 patients with malignant bladders, DW MRI detected 32of 34 tumors with 2 false negative findings of lesions in 2 patients. In 23 patients with non malignant bladders, the DW MRI data was accurate for 21 patients, as 2 patients were misdiagnosed as malignant. The sensitivity, specificity, accuracy positive and negative predictive values of DW MRI for identifying bladder tumors were 91.6%, 95.6%, 93.6%, 95.6 and 91.6 respectively. Using McNemar test there was no statistical significant difference between DW and cystoscopy.

Conclusion: DW MRI has a high reliability in differentiating post TUR inflammatory changes from bladder tumors similar to cystoscopy and could be a first line diagnostic test in follow-up of patients after TUR.

www.esur2013.org 24 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS13 MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING HELPS TO DIFFERENTIATE COMMON SUBTYPES OF RENAL TUMORS Tricaud E. 1, Cornelis F. 1, Le Bras Y. 1, Roy C. 2, Grenier N. 1 CHU de Bordeaux Radiology Bordeaux-France 1 CHU de Strasbourg Radiology Strasbourg-France 2

Purpose:To evaluate the ability of Magnetic Resonance (MR) imaging to differentiate common types of renal tumors through a combination of MR parameters derived from routinely-performed sequences.

Materials and methods:MR images from 100 pathologically-proven renal tumors with no macroscopic fat (57 clear-cell, 16 papillary, and 7 chromophobe renal cell carcinomas (RCCs), 16 oncocytomas and 4 minimal fat angiomyolipomas (AMLs)) treated at a single institution between 2009 and 2012 were evaluated. Two radiologists blind to pathology results reviewed independently double-echo chemical shift, T1-weighted and T2-weighted images, and ADC maps. Signal intensity index (SII) and tumor-to-spleen SI ratio (TSR), ADC ratio, wash-in index (WiI) and wash-out index (WoI) between different phases (arterial, parenchymal or late) were calculated. Results were analyzed with Wilcoxon sum rank, Fisher ’s exact tests and receiver operating characteristics..

Results: There were significant differences between papillary RCCs and other renal tumors for arterial WiI (P<0.001, area under the curve (AUC)=0.92), initial WoI (P=0.006, AUC=0.72) and ADC ratio (P<0.001, AUC=0.85); between chromophobe RCCs and oncocytomas for TSR (P=0.02, AUC=0.8), parenchymal WiI (P=0.03, AUC=0.74), late WiI (P=0.02, AUC=0.77), initial WoI (P=0.03, AUC=0.8) and late WoI (P=0.04, AUC=0.79); and between clear-cell RCCs and oncocytomas for SII (P=0.01, AUC=0.71) and parenchymal WiI (P=0.01, AUC=0.69). Multiparametric analysis accurately distinguished papillary RCCs from other renal tumors (sensitivity: 37.5%, specificity: 100%) and oncocytomas from chromophobe and clear-cell RCCs (sensitivity, specificity of 25%, 100% and 18.7%, 94.2%, respectively). Conclusions: Differentiation of most common renal tumor types is possible using combinations of multiparametric MR imaging criteria.

MDSS14 RADIOLOGICAL CHARACTERIZATION OF TUBULO-CYSTIC RENAL CELL CARCINOMAS Cornelis F. 1, Hélénon O. 2, André M. 3, Lhermitte B. 4, Lemaitre L. 5, Grenier N. 1 CHU de Bordeaux Radiology Bordeaux-France 1 AP-HP Radiology Paris-France 2 AP-HM Radiology Marseille-France 3 CH de Lausanne Radioogy Lausanne-Switzerland 4 CHU de Lille Radiology Lille-France 5

Objectives: To determine if tubulo-cystic carcinomas (CTK) kidney have specific radiological features.

Materials and methods: Multicenter retrospective analysis from 2002 to 2013 of imaging of 15 patients (mean age 55.7 years, 26-76, 13 men, 2 women) with histologically proven CTK. All patients underwent an ultrasound followed by a CT-scan (n = 10) and / or MRI (n = 6). An independent review was performed by two radiologists to identify the imaging characteristics without and after injection of contrast product. A review of all pathological reports was also performed.

Results:The tumors measured 12 to 140 mm (mean: 35). On ultrasound, they were all hyperechoic with posterior enhancement. On CT, 20% (2/10) were classified according to type 1-2 Bosniak, 30% (3/10) 3-4 and 50% (5/10) tissue. On MR imaging, 100% (6/6) appeared hyperintense on T2weigted sequences and showed an enhancement. Two cases were associated with papillary tumors and one case presented a hybrid form.

Conclusion: CTK have characteristic imaging features able to identify this uncommon histological type. In case of hyperechoic renal lesion, further examination with injection (on CT or MRI) should be performed.

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MDSS15 PRIMARY CARE DIRECT ACCESS CT KUB FOR SUSPECTED URINARY TRACT CALCULI AT A UNIVERSITY HOSPITAL - ONE YEAR EXPERIENCE Cook N. 1, Grima M. 1, George C. 1 University Hospital of North Staffordshire Imaging Stoke-on-Trent-United Kingdom 1

Objective: Unenhanced computed tomography of the kidneys, ureters, and bladder (CT KUB) is the imaging gold standard for the diagnosis of urinary tract calculi. We assess the usefulness of direct access CT KUB that has been made available to the primary care doctors in our region.

Method: The referral details and imagining results were analysed retrospectively and compared with the national standards published by the Royal College of Radiologists in the United Kingdom.

Results: The yield of positive examinations for urinary tract calculi was 37% (58/157), slightly less than the national standard of 44-62%. If criteria such as passed calculi and rejected requests where haematuria was negative, the yield would have increased to 43%. 91% (53/58) of the patients who had urinary tract calculi had haematuria. 16% (25/157) of the scans revealed an alternative diagnosis that was within the national standard of 6-18%. In 47% (73/157) of the patients there was no radiological abnormality.

Conclusion:Our results demonstrate that direct access CT KUB pathway is an effective service which allows prompt diagnosis of urinary tract calculi in the primary care setting. It helps avoid unnecessary hospital admissions and urology outpatient referrals both of which have cost saving implications. We report our one year initial experience and identify factors that will need to be implemented so that our service and outcome will improve.

MDSS16 DYNAMIC SINGLE-SLICE CT UROGRAPHY WITHOUT TABLE FEED – NEW TECHNIQUE TO RULE OUT RENAL OBSTRUCTION Dahlman P. 1, Segelsjö M. 1, Magnusson A. 1 Uppsala University Hospital Dept of Radiology Uppsala-Sweden 1

Background: Patients with suspected urinary calculi undergo unenhanced CT. Ureteral calculi can cause obstruction without indirect signs of obstruction visible at unenhanced CT. A technique with low radiation dose and low iodine load is wanted to rule out obstruction.

Aim: In this pilot study a new technique is evaluated; dynamic single-slice CT urography.

Material and Methods: Forty-five consecutive patients, mean age 58±17 (min 20, max 80) years presenting with suspected calculi 4 weeks earlier and diagnosed with ureteral stone at unenhanced CT (Siemens Definition Flash 120kV, ref eff mAs 60) were included in the study. Patients underwent additional dynamic single-slice CT at the level of the renal hili with no table feed following 30 ml Iomeron 400mgI/ml (100kV, ref eff mAs 40, slice thickness 10 mm). The scan was repeated every 10 sec until 1 min and then every 30 sec until contrast was excreted. Effective radiation dose estimated from DLP.

Results: In all of the included patients contrast enhancement and excretion could be safely evaluated with dynamic single-slice scans. Mean number of single-slice scans was 8, and the mean additional DLP was 9±2 (min 8, max 14) mGycm approx 0,15 mSv compared to the mean DLP from the unenhanced scan 136±29 (min 83, max 168) mGycm approx 2,3 mSv.

Conclusion: Single-scan dynamic CT urography is a simple, quick and safe method to rule out obstruction in patients with ureteral stones. A low dose of contrast (30 ml, 400 mgI/ml) is used and the additional radiation dose is low.

www.esur2013.org 26 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS17 MR RENAL IMAGING USING A 3D T1-WEIGHTED TWO-POINT DIXON SEQUENCE AT 3T Roy C. 1, Host P. 1, Aleman G. 1, Ohana M. 1, Lang H. 2 Universitary Hospital Strasbourg Radiology B Strasbourg-France 1 Universitary Hospital Strasbourg Urology Strasbourg-France 2

Purpose: Standard fat suppression techniques such as 2D chemical shift (IP/OP) and spectral saturation sequences are a workhorse of renal MRI. The purpose of this study was to assess whether DIXON with four contrasts can be an efficient alternative to those standard techniques in terms of uniform fat suppression, image quality, confidence diagnosis and examination time.

Method And Materials:158 patients referred for kidney MR examination (68 normal , 75 carcinomas, 15 angiomyolipomas ) underwent on a 3T MR unit in addition to our routine protocol three axial T1w fat suppression techniques : Group A (spectral saturation FFE, 5 mm, 28 slices- 25 sec), Group B (2D chemical shift FFE with IP/OP images, 5mm, 32 slices- two breathholds of 28 sec) and Group C (3D two-point Dixon, 1.8mm, 100 slices, 15s) with IP/OP/W/F images reconstructed. Qualitative and quantitative analysis were performed by two readers independently.

Results:On qualitative analysis, a statistically significant difference was found in overall image quality and fat suppression characteristics. Both readers agreed that the degree of fat saturation was greater with Dixon without any displacement artifacts. Performances of the sole DIXON were excellent for the identification of tumoral process, fatty component as well as hemorrhagic part (sensibility = 96%, sensitivity = 100%)

Conclusion:The 3D two-point Dixon sequence achieved superior image quality and fat saturation in a shorter acquisition time with four informations. It can replace in daily routine standard fat suppression techniques.

MDSS18 THE ROLE OF STRAIN ELASTOGRAPHY IN DIFFERENTIATION BETWEEN BENIGN AND MALIGNANT RENAL MASSES Mehmet Ruhi Onur ,Ahmet Rahmi Onur,Irfan Orhan, University of Fırat Faculty of Medicine Department of Urology, Elazığ

Objective: The aim of our study was to understand the role of strain elastography in differentiation between benign and malignant solid renal masses.

Method: Twenty eight patients (15 female, 13 male; mean age: 54, age range: 16 - 76) with renal masses obtained at ultrasonography were included in this study. Strain index values of renal masses representing ratio of strain values of masses and renal parenchyma were measured with strain elastography technique on ultrasound machine. All patients with renal masses were assessed with contrast enhanced computed tomography (CT). Twenty one patients were assessed with magnetic resonance imaging (MRI). Sixteen patients with malignancy suspicion were operated.

Results: Eleven of renal masses were diagnosed as angiomyolipoma according to CT and MRI examinations. The histopathologic examination of 16 renal masses revealed 13 renal cell carcinoma, 2 transitional cell carcinoma and 1 oncocytoma. The strain index values of benign and malignant renal masses were 1.7 ± 1.0 (ranging between 0.71 – 4.17) and 3.76 ± 1.98 (ranging between 1.8 – 7.4), respectively. There was significant difference between strain index values of benign and malignant renal masses (P = 0.0024).

Conclusion: The strain index values of malignant renal masses are higher than benign renal masses. Strain elastography may be used as a semiquantitative ultrasound elastography technique in differentiation between benign and malignant renal masses.

27 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

MDSS19 VASCULAR FEATURES IN 36 CASES OF TESTICULAR LYMPHOMA AND 9 MIMICS AT COLOR- DOPPLER US M. Bertolotto, L.E. Derchi, M. Secil, V. Dogra, P. Sidhu, R. Clements, S. Freeman, N. Grenier, L. Mannelli, L. Rocher, J. Spencer, A. Tsili, M. Valentino

Purpose: No matter if the macroscopic appearance is nodular or diffuse, in testicular lymphoma tumor cells grow infiltrating through the tubules and through the normal testicular vessels; therefore, the normal vascular architecture of the testis is preserved.

Aim: To investigate the grey-scale and Doppler features of a relatively large series of testicular lymphoma, and to evaluate whether identification at color Doppler ultrasound of testicular vessels with straight course crossing a mass improves lesion characterization Materials and Methods: through a ESUR Call for Scientific Cooperation the teaching files archived as suspicious testicular lymphoma in different research centres were retrospectively reviewed. Cases in which color Doppler images were available were reexamined to assess the features of the lesion, either mass forming or diffuse, and presence of normal testicular vessels with straight course crossing the lesion. Inclusion criteria were met by 36 patients with pathologically-proven lymphoma and 9 patients in whom lymphoproliferative disease was suspected on clinical and US ground and pathology or clinical evolution showed non-neoplastic disease.

Results: Lymphoma patients age ranged 23-84y (median: 64y). Five had testicular involvement in sistemic disease; 31 had primary disease. Five had bilateral involvement. Patients with inflammatory mimics had proven non-specific inflammation (n=4), granulomatous orchitis (n=2) Brucellosis (n=2) and tuberculosis (n=1). Involvement of the testis was focal in 19/36 patients with lymphoma, diffuse in the others. Involvement was focal in 5/9 mimics. Color Doppler US demonstrated normal testicular vessels with straight course within the tumor in 28/36 (78%) cases of lymphoma and in 7/9 (78%) mimics.

Conclusions: In patients over 60 and/or with history of lymphoproliferative disease presenting with a testicular mass lymphoma must be considered; Demonstration of normal testicular vessels crossing the lesion is a useful adjunctive criterium to confirm the diagnosis. Inflammatory lesions may present the same imaging features as lymphoma.

www.esur2013.org 28 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY LECTURE SESSIONS

Lecture Session 1: Imaging of Renal Tumors Moderators: Isaac R. Francis, Hiromu Mori

LS1a Imaging and Management of Incidental Renal Masses Seung Hyup KIM, M.D. Professor of Radiology and Urology, Seoul National University Hospital, Seoul, Korea

Technical advances and popular use of imaging studies result in frequent detection incidentally detected renal masses (IDRMs). Many IDRMs are found at CT scan underwent for non-renal indications while many IDRMs are also found at US studies done as a part of routine physical check-up. IDRMs detected first at US usually need to be further investigated with contrast-enhanced CT.

The most common IDRMs are benign renal cysts. Solid IDRMs should be considers as renal cell carcinomas (RCCs) unless proven otherwise. Recently more than 50% of all RCCs are detected incidentally. Incidentally detected RCCs are more likely small and organ-confined with better prognosis. When a solid IDRM is found, the most important roles of imaging is differentiation between benign and malignant lesions. Differential diagnosis of solid IDRMs includes RCCs, adenomas, angiomyolipomas (AMLs), oncocytomas (OCTs), urothelial carcinomas, lymphomas and metastatic tumors. Other non-neoplastic renal lesions such as congenital, inflammatory, or vascular lesions may appear as solid IDRMs. Various causes of renal pseudotumors are also important causes of IDRMs. Some IDRMs are too small to characterize further using any imaging modality, but most of IDRMs can be accurately characterized by using proper imaging modalities.

Cystic IDRMs are evaluated on the basis of Bosniak classification. Bosniak proposed a 4-category classification system in evaluating cystic renal masses. He proposed this classification with CT findings, but it can be applied to US or MRI findings as well. Class I lesion indicates a clearly simple cyst; Class II lesion indicates a minimally complicated cyst with thin septa, most likely a benign cyst; Class III lesion is a more complicated lesion that has complex and thick septa, often solid nodules. Because class III lesion has high possibility of a malignancy, further evaluation or surgery is necessary; Class IV lesion is obviously a malignant lesion and the patient definitely need surgery. With this classification system, always the problem was differentiation between class II and III, so later class IIF was added, which is a little bit more complicated than class II but less than class III, and so need close follow up.

Differential diagnosis of solid IDRMs is basically between a RCC and other renal tumors. About 15~20% of small solid CT-enhancing renal masses are benign renal neoplasms such as OCTs or AMLs. The diagnosis of AML is straightforward if it has gross amount of fat, but not infrequently AML does not have enough fat that can be visible at CT or MRI. Differentiation between a RCC and an AML with minimal fat (mfAML) is most difficult part. There has been number of studies focusing on differentiation between mfAML and RCC using various techniques and criteria with none showed perfect solution. Renal OCT is the second most common benign renal parenchymal tumor after AML. Central stellate scar and spoke-wheel pattern of arterial enhancement have been reported as characteristic imaging findings of OCT, but those findings are usually not seen when OCTs are small. Recently segmental enhancement inversion during corticomedullary and excretory phase CT images was reported as a characteristic enhancement pattern of small OCTs. Still preoperative imaging characterization of small renal parenchymal tumors is an unsolved and ongoing issue, but familiarity with findings at multimodality imaging studies will be helpful.

There are various histologic subtypes of RCCs with clear cell type (ccRCC) being the most common, which is usually hypervascular and shows strong heterogeneous contrast enhancement in early-phase CT or MRI. Papillary RCC (papRCC) commonly show homogeneous, weak, and persistent contrast enhancement, and it may be difficult to distinguish from mfAMLs or OCTs. There are two types of papRCCs, type 1 and 2. Type 2 papRCC shows more aggressive appearance than type 1 papRCC. Chromophobe RCC (cpRCC) shows enhancement characteristics between those of ccRCC and papRCC. Familiarity with various imaging findings RCCs according to histologic subtypes is important because there are significant differences in prognosis among different histologic subtypes.

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Image-guided biopsy of IDRMs is increasingly being used. Renal tumor biopsies are used increasingly also in metastatic patients before starting therapy, in follow-up surveillance, and in ablative therapies. The accuracy of renal mass biopsy is being improved with a decreasing rate of non-diagnostic results. For small renal masses, CT-guided biopsy is being used more frequently than US-guided biopsy.

Radical nephrectomy is the standard mode of management of a large RCC. Currently standard technique of small RCC is nephron sparing surgery such as open or laparoscopic partial nephrectomy. Ablative therapies such as radiofrequency ablation or cryoablation through open incision, laparoscopic or percutaneous route is an alternative management mode in patients with poor surgical candidate. The concept of active surveillance is another alternative management for IDRMs detected in elderly patients with decreased life expectancy or medical comorbidities.

LS1b Expanding role of imaging as a guidance to renal sparing treatment and its complications” Prof Francesco M. Danza Radiology, Chief of Emergency section Dept of bioimaging and radiological sciences Università Cattolica del S Cuore, Rome Italy

“There was a time when a renal cancer was just a renal cancer: a solid enhancing mass in the kidney that required no further description and was removed with a radical nephrectomy. As radiologists, we staged the mass according to whether it invaded the renal capsule, whether enlarged lymph nodes were present, and whether the renal vein and inferior vena cava were involved and then we went on to the next case, leaving histology to the pathologists” Peter L. Choyke from Radiographic , 2006. Now the scenario is dramatically changed: two different facts contributed to change the management of renal tumors: first the ability of urologists to resect renal lesions with respect of renal parenchyma: partial resections, enucleations and ablations are today alternative to nephrectomy and represent the preferred surgical treatments for the smaller tumors. When nephron sparing surgery (NSS) is feasible, its results vs radical nephrectomy do not differ in terms of oncologic outcome . Second the diffusion of MDCT with high spatial and temporal resolution, offered a beautifull demonstration of renal anatomy, from vascular structures to renal lodge details with emphasis for functional considerations. The possibility to detect and characterize small renal masses under ten millimeters is now expanded. In such a scenario Radiology has increased its possibility to respond to the questions coming from the clinical counterpart in order to realize the best treatment with the maximum sparing of parenchyma.

The role of imaging is to day expressed at different levels: detection of small renal masses, solid or cystic, is increasing, being the diagnosis of renal tumors done, in many cases, during imaging studies performed for non-renal symptoms. And also the number of US, CT and MR studies performed for various abdominal symptoms is increasing: many are the renal lesions seen during MR evaluation of the spine. There is an increase of numbers of diagnosed and treated RCCs, but there is also increased survival for these patients, and imaging has played a key role. Today, most renal tumors are discovered at T1 or T2 stage. Before the development of MDCT, lesions < 3 cm were 5%; they are now between 9% and 38%. Tumor stage at diagnosis is one of the most important prognostic factors in Pts with RCC.

RCCs are not one single tumor: malignancies of different histologic types origine from different cells within the kidney: Clear cells, Papillary, Chromophobe, Bellini type, Mesenchymal tumors. Benign solid masses are Oncocytoma, Mesenchymal tumors, AML, Leiomyoma, Juxtaglomerular tumor, Fibroma, Lipoma, Hemangioma. Is it important to differentiate them preoperatively because benign solid nodules are demonstrated in 20-30 % of all resected lesions <3 cm: oncocytomas and AMLs are the most common. To recognize them and avoid unnecessary surgery is a fundamental job for imaging. It is easy to recognize an AML when there is easily-visible fat in it, more critical is the diagnosis in Fat-poor tumors.

It may even be possible to differentiate tumors of different histology within the same kidneys. Multicentricity and bilaterality of RCC is considered uncommon (2%-5% of patients). Asynchronous, contralateral tumor development is seen in 2% of patients who undergo radical nephrectomy for RCC. Nevertheless, multicentricity, which includes microscopic foci of RCC, is reported in up to 25% of radical nephrectomy specimens. These numbers will likely change with improved detection. The clinical behavior and prognosis is quite different: Clear Cells Ca – 65% of all lesions: 90% metastases versus Papillary and Chromophobe

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Ca – 25% of all lesions: 10% metastases. 4%-5% of RCCs have a hereditary association. Hereditary tumors tend to be multiple, bilateral, and develop at an earlier age in both sexes and multicentric tumor development should prompt consideration of a hereditary condition. The list of hereditary associations is growing and all tumor subtypes are represented.

Evaluating morphological and functional aspects as structure, vascularization, and necrosis characterization is frequently successfully obtained. High enhancement and heterogeneity significantly associated with aggressive lesions. A confounding factor is the presence of areas of necrosis in large, less aggressive tumors. The new possibility of perfusion (CT) and diffusion (MRI) expand very much the benign-malignant differential diagnosis.

Differentiation may help physicians stratify individualized treatment, estimate probability of tumor recurrence, design rational follow-up regimens and provide patient counseling; furthermore, it may be potentially useful in clinical trials.

Recently some methods are proposed (“C-index”, “Padua” and “Renal”) to guides surgical planning and provide clues to best surgical approach; both are prognostic factors to complications: all these methods are based on imaging able to furnish preoperative knowledge of renal vascular anatomy and tumor location (spatial localization) and staging. For example Patients with PADUA score 6 – 7 had significantly less complications than those with higher scores. So an accurate preoperative imaging is the key factor in deciding NSS feasibility and in guiding “how to do” it.

Percutaneous biopsy has not been frequently employed in patients with renal masses. “Classical” indications to biopsy of renal masses are: renal vs metastatic disease in patients with known extrarenal primitive neoplasm; dd with abscess, renal infection or lymphoma; histologic confirmation of a primitive renal tumor with disseminated met disease or huge, retroperitoneal, non resectable mass. Two main factors have recently increased the role of percutaneous biopsy of renal masses to provide a tissue diagnosis before a therapeutic decision: imaging detection of a high number of asymptomatic small solid renal nodules (19-27% benign) and the development of focal ablation techniques for renal tumors. There are still some diagnostic problems: oncocytomas seem difficult to differentiate from Chromophobe Carcinomas (need for special stainings, need for large/cutting needles). Percutaneous biopsy can be problematic in patients with cystic renal neoplasms (limited tissue is often aspirated). Hemorrhagic fluid and atypical cells found also in benign lesions. Up to 16% of tumors have internal heterogeneity, with different Furham grades.

The new nephron sparing surgery have expanded the spectrum of complications, due to the different approach to the renal parenchima and its excretory system, which remain in place and can be source of many adverse events in postoperative period. As in conventional surgery radiological imaging is the gold standard for control and follow-up (hematoma, urinoma, vessel thrombosis, abcess).

Each one of these points is important for the success of treatment and now radiologist have the opportunity to enter in the multidisciplinary group of renal tumor management with urologists and oncologists.

LS1c Is it time to develop guidelines for the follow-up of treated RCC? Imaging perspective. M.F. Bellin (Paris Sud University, France), N. Grenier (Bordeaux University, France)

The management of RCC has significantly changed over the past 2 decades. To prevent unnecessary removal of the entire kidney to treat a small renal mass, partial nephrectomy and nephron-sparing surgery have progressively replaced the “gold standard” of radical nephrectomy for patients in whom complete removal of the tumor is possible without compromising the remnant portion of the kidney. In addition, because of several benefits over the extirpative approach, ablative methods have expanded considerably. Active surveillance is reasonable for some patients. More recently, the introduction of targeted therapy has significantly improved the perspectives of patients with metastatic RCC.

Radiologists play an important role in long-term follow-up of patients with RCC, which includes patient’s history, physical examination, laboratory tests, and radiographic evaluation. However, a consensus surveillance protocol does not exist for every post-therapeutic context and there is no evidence that any

31 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY particular follow-up protocol influences the outcome in early RCC. Surveillance after treatment of RCC allows the radiologist to identify and monitor: -postoperative or post-procedural complications, -local recurrence after partial nephrectomy or ablative treatment, -recurrence in the contralateral kidney, -development of metastases, -and follow-up of antiangiogenic therapies.

Therefore, we do think that guidelines for follow-up of treated RCCs are now mandatory.

Techniques Generally, CT is considered the most important imaging technique in postoperative surveillance. It is the only technique, in that context, allowing a complete evaluation from brain to pelvis. MR imaging plays a growing role in clinical practice, depending on the level of renal function and on the type of applied therapy, but it is essentially used at the renal level for detection of local recurrences or new localizations. However, it may be used, as CT or sonography in any location for evaluation of antiangiogenic drugs.

Using CT, the protocol should include unenhanced and enhanced images to detect the presence of enhancement in any lesion of interest. Enhanced images should be obtained during the corticomedullary and nephrographic phases, because the degree of enhancement varies according to tumor types. Metastases from clear cell RCCs often show a very high enhancement at the vascular phase and may disappear at the nephrographic phase.

Using MRI, several sequences are required : axial GE T1w (in phase and out-of-phase), axial (± coronal) TSE T2w images, axial diffusion-weighted sequence and dynamic contrast-enhanced sequence. Specific functional acquisitions with CT, MRI or US still need a consensus before to be displayed in general clinical practice.

After surgery or ablation The majority of recurrences occur within the first 5 years after surgery or ablation, supporting a more intense follow-up strategy within the first 5 years. However, patients with hereditary conditions predisposing them to development of multifocal RCC likely require lifetime surveillance imaging. Early identification and treatment of RCC recurrence have been shown to improve cancer-specific survival in selected patients.

After surgery, no standard protocol exists but, in most institutions, the initial control is performed 3-6 months after surgery, and regular checkups will continue, especially in the early years. The ideal follow-up imaging scheme depends on several factors including the prognostic factors for recurrent disease (TNM stage, histologic type, Fuhrman grade, etc…), treatment options, diagnostic performances of imaging modalities regarding each potential metastatic site, chronology and sites for recurrence, therapeutic possibilities upon recurrence. Several schemes are proposed in the literature. Most of them are based on the UISS (UCLA Integrated Staging System) stratification, the natural history of RCC, and available treatment modalities. After ablation, the standard protocol includes a first control between 2 and 3 months after ablation (technical control to look for residual tumor and for complications), then at 6 and 12 months and at 12-month interval thereafter during 5 years at least (for identifying tumor recurrence, metastatic disease, new tumors, and delayed complications). After RF ablation, CT and MR imaging, with the upper mentioned protocols, may be used with equal performances, depending essentially on the level of renal function. After cryo-ablation, the changes of signal intensity in the ablation zone with MRI may be more complex.

After antiangiogenic treatment In patients with metastatic RCC who have received antiangiogenic targeted therapy, recent data have shown the inadequacy of RECIST criteria in assessing tumor response because tumor necrosis resulting from the antivascular effect of antiangiogenic drugs is not taken into account by RECIST criteria. With CT and MR imaging, the Choi criteria, the modified Choi criteria, or the size and attenuation CT (SACT) criteria may be more appropriate to assess tumor response. Functional imaging techniques are still under investigation.

In this lecture, we will discuss the main objectives of follow-up in patients with RCC and show the imaging findings after treatment of RCC, including the postoperative changes, complications, and tumor recurrence aspects. We will also discuss:

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-the diagnostic performances of currently available imaging techniques for the detection of recurrence after nephrectomy, -the imaging protocols that can be used to assess tumor response and recurrence after targeted therapies, -how to stratify patients according to their relative risk of recurrence, -the main schemes for follow-up that are proposed in the literature, -and finally the need for new guidelines regarding follow-up of treated RCC. In the future, imaging studies in combination with molecular markers may allow more personalized surveillance strategies.

References 1.Choi H. Response evaluation of gastrointestinal stromal tumors. Oncologist 2008; 13: 4-7 2.Donat SM, Diaz M, Bishoff JT, et al. Follow-up for clinically localized renal neoplasm: AUA guideline. J Urol 2013; 190: 407-416 3.Lam JS, Shvarts O, Leppert JT et al. Postoperative surveillance protocol for patients with localized and locally advanced renal cell carcinoma based on a validated prognostic nomogram and risk group stratification system. J Urol 2005; 174: 466-472 4.Siddiqui S, Frank I, Cheville JC et al. Postoperative surveillance for renal cell carcinoma: a multifactorial histological subtype specific protocol. BJU Int 2009; 104: 778-785 5.Wile GE, Leyendecker JR, Krehbiel KA, et al. CT and MR imaging after imaging-guided thermal ablation of renal neoplasms. RadioGraphics 2007; 27: 325-341

LS1d Is it time to develop guidelines for the follow-up of treated RCC? Clinical perspective Öner Şanlı

33 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Lecture Session 2: Controversies in Prostate Cance Imaging Moderators: Jonathan Richenberg, Jelle Barentsz

LS2a What does Urologist expect from Uro-Radiologist on detection/staging of PSA detected PCa? Bob Djavan

LS2b Prostate biopsy after MRI: cognitive fusion with TRUS? MR-guided? TRUS/MRI fusion? Masoom Haider, Jurgen Futterer, Alex Kirkham

Masoom Haider Multiparametric MRI (mpMRI) has been shown in multiple studies to identify the index tumor and help improve yields of prostate biopsy. TRUS prostate biopsy is performed by urologists in most health care systems while MRI biopsy is more expensive, less available and is performed by radiologists. It makes economic sense to determine whether biopsy strategies that use mpMRI combined with TRUS have sufficient diagnostic yields to alleviate the need for a more expensive MRI guided biopsy approach. As clinically significant tumor are of higher volume the need for direct MRI biopsy is questionable. Cognitive registration with increased sampling in a suspicious area with TRUS is a reasonable, low cost first approach. The merits and pitfalls of cognitive coregistration and computer based fusion of MRI and TRUS Images for biopsy will be discussed and debated

Jurgen Futterer Prostate cancer continues to be a major health problem in developed countries, accounting for an estimated 29% (240,890) of new cancer cases and 11% (33,720) of cancers deaths in men in the United States in 2011.Over the past years, the value of multi-parametric magnetic resonance imaging (MRI) in localizing PCa has been well established. High diagnostic accuracy can be achieved using the lattertechnique. Similarly, MR imaging has been proposed in directing biopsies towards cancer suspicious regions within the prostate, in order to improve diagnostic performance of the procedure. In recent years, MR-guided biopsy (MRGB) for the detection of prostate cancer has been increasingly applied in the clinic. Reported prostate cancer detection rates ranged from 8-59% (median 42%). The majority of tumors detected by MRGB was clinically significant. Most frequent complications of MRGB are transient hematuria (1-24%) and short-term perirectal bleeding (11-17%). Major complications are rare. MR-guided prostate biopsy can thus be regarded an accurate and safe diagnostic tool to detect clinically significant prostate cancer.

LS2c Endorectal coil for mpMRI: Is it necessary?: Barış Turkbey, Vibeke Logager, Sadhna Verma, Francois Cornud, Debate and vote

Barış Turkbey Multi-parametric MRI is emerging as an important tool for localizing prostate cancer (1-13). This success is based on several factors: improved signal-to-noise ratios derived from the use of combined endorectal and surface coil arrays, higher field strength magnets, and the expanded use of multiparametric magnetic resonance imaging (MRI) (T2 weighted [T2W] MRI, diffusion weighted [DWI] MRI, MR spectroscopy and Dynamic Contrast Enhanced [DCE] MRI). Despite an extensive supportive literature on prostate MRI, endorectal coil MRI is still not commonly used; contributing factors include anticipated discomfort associated with the endorectal coil, costs related to reimbursement of the coil and lack of expertise. Avoiding the use of an endorectal coil could improve the palatability of prostate MRI from the physicians’, payors’ and patients’ perspective. Recently, several groups have reported comparable performance between non-endorectal coil MRI of the prostate at 3T and endorectal dual coil MRI at 1.5T (2, 7, 14-17). However, the number of studies in which direct comparisons of endorectal dual coil and non-endorectal coil MRI done at 3T is still limited (7). It has been established that dual surface and endorectal coils improve the image quality and performance of prostate MRI for lesion detection and staging (10). On the other hand, a non-endorectal coil MRI may not always able to detect all tumors and is inferior in determining the presence of extracapsular extension of the

www.esur2013.org 34 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY tumor. Therefore, while endorectal coil MRI is not always practical, the implications and limitations of a non- endorectal coil examination should be understood. It could be argued that the endorectal dual coil method simply detects more inconsequential prostate cancers which could lead to over treatment. However, in our experience, some of the missed lesions could be life threatening. Methods are under development to detect “lethal signatures” based on biopsy specimens of prostate cancer and this may influence the conservative management of these small, detected lesions. However, until it is possible to predict with certainty which tumors will progress to metastases and which will remain indolent, Gleason scoring and lesion size will remain the only parameters for estimating tumor aggressiveness. Both have well known limitations. In this regard, non-endorectal coil MRI may miss a significant number of lesions of significant tumors. In this lecture, the strengths and limitations of endorectal coil MRI will be compared with a non-endorectal coil MRI approach based on the literature and personal experience.

References 1.Kim CK, Park BK, Kim B. Localization of prostate cancer using 3T MRI: comparison of T2-weighted and dynamic contrast-enhanced imaging. J Comput Assist Tomogr. 2006;30:7-11. 2.Park BK, Kim B, Kim CK, et al. Comparison of phased-array 3.0-T and endorectal 1.5-T magnetic resonance imaging in the evaluation of local staging accuracy for prostate cancer. J Comput Assist Tomogr. 2007;31:534-538. 3.Fütterer JJ, Heijmink SW, Scheenen TW, et al. Prostate cancer localization with dynamic contrast- enhanced MR imaging and proton MR spectroscopic imaging. Radiology. 2006;241:449-458. 4.Kim CK, Park BK, Lee HM, et al. Value of diffusion-weighted imaging for the prediction of prostate cancer location at 3T using a phased-array coil: preliminary results. Invest Radiol. 2007;42:842-847. 5.Ocak I, Bernardo M, Metzger G, et al. Dynamic contrast-enhanced MRI of prostate cancer at 3 T: a study of pharmacokinetic parameters. AJR Am J Roentgenol. 2007;189:849. 6.Scheenen TW, Heijmink SW, Roell SA, et al. Three-dimensional proton MR spectroscopy of human prostate at 3 T without endorectal coil: feasibility. Radiology. 2007;245:507-516. 7.Heijmink SW, Fütterer JJ, Hambrock T, et al. Prostate cancer: body-array versus endorectal coil MR imaging at 3 T--comparison of image quality, localization, and staging performance. Radiology. 2007;244:184- 195. 8.Miao H, Fukatsu H, Ishigaki T. Prostate cancer detection with 3-T MRI: comparison of diffusion-weighted and T2-weighted imaging. Eur J Radiol. 2007;61:297-302. 9.Zhang J, Hricak H, Shukla-Dave A, et al. Clinical stage T1c prostate cancer: evaluation with endorectal MR imaging and MR spectroscopic imaging. Radiology. 2009;253:425-434. 10.Turkbey B, Pinto P, Mani H et al. Prostate cancer: value of multiparametric MR imaging at 3 T for detection--histopathologic correlation. Radiology. 2010;255:89-99. 11.Rosenktrantz AB, Neil J, Kong X et al. Prostate cancer: Comparison of 3D T2-weighted with conventional 2D T2-weighted imaging for image quality and tumor detection. AJR 2010;194:446-452. 12.Riches SF, Payne GS, Morgan VA et al. MRI in the detection of prostate cancer: combined apparent diffusion coefficient, metabolite ratio, and vascular parameters. AJR 2009;193:1583-1591. 13.Kitajima K, Kaji Y, Fukabori Y et al. Prostate cancer detection with 3 T MRI: comparison of diffusion- weighted imaging and dynamic contrast-enhanced MRI in combination with T2-weighted imaging. J Magn Reson Imaging. 2010;31:625-631. 14.Sosna J, Pedrosa I, Dewolf WC, Mahallati H, Lenkinski RE, Rofsky NM. MR imaging of the prostate at 3 Tesla: comparison of an external phased-array coil to imaging with an endorectal coil at 1.5 Tesla. Acad Radiol. 2004 ;11:857-862. 15.Torricelli P, Cinquantini F, Ligabue G, Bianchi G, Sighinolfi P, Romagnoli R. Comparative evaluation between external phased array coil at 3 T and endorectalcoil at 1.5 T: preliminary results. J Comput Assist Tomogr. 2006 ;30:355-361. 16.Fütterer JJ, Engelbrecht MR, Jager GJ, Hartman RP, King BF, Hulsbergen-Van de Kaa CA, Witjes JA, Barentsz JO. Prostate cancer: comparison of local staging accuracy of pelvic phased-array coil alone versus integrated endorectal-pelvic phased-array coils. Local staging accuracy of prostate cancer using endorectal coil MR imaging. Eur Radiol. 2007 ;17:1055-1065. 17.Kim B, Breau RH, Papadatos D, Fergusson D, Doucette S, Cagiannos I, Morash C. Diagnostic accuracy of surface coil magnetic resonance imaging at 1.5 T for local staging of elevated risk prostate cancer. Can Urol Assoc J. 2010 ;4:257-262.

35 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Vibeke Logager Endorectal coil magnetic resonance imaging (MRI) is a technique in which the coil is embedded in an inflatable balloon, inserted in the rectum in order to come as close as possible to the organ of interest, in this case the prostate. The closer to the organ, the better signal can be received and hereby higher resolution. It is important to detect all lesions since Prostate cancer is a multifocal diseases. To stage correctly it is necessary to evaluate the capsule and surroundings (i.e. neurovascular bundle) in order to offer the patient the best and relevant treatment. In prostate cancer, the highest image quality and also the highest accuracy in detecting and staging prostate cancer. The use of endorectal coil is mandatory when only 1.5 T is available or if spectroscopy is desired. In case of detection of recurrence resolution is even more important since the local recurrence can be very small, located at the vescico -urethral junction.

In multiparametric MRI of the prostate it is possible to achieve also high signal and resolution in the dynamic contrast enhanced sequences which further improves detection and staging.

Despite eventually minor discomfort when placing the endocoil, it can to some degree prevent the prostate from moving and thereby minimize artefacts. Furthermore it is possible to fill the coil with different liquids if desired to avoid susceptibility artefacts.

Endorectal coil has high negative predictive value and confirmative focused biopsies can upgrade Gleason score in 20 % of cases (N=79 of 388 patients) Vargas HA: The Journal of Urology September 26th 2012. This topic will be further discussed at this session.

François Cornud Local staging of prostate cancer (PCa) remains a debate. Historically, MRI performs much less well without the use of a rectal coil, but comparison with results of the endorectal coil has not been done with last generations magnets. Moreover, the question in 2013 is to know what kind of local staging we need. High risk tumors with established extra capsular extension (ECE) on MRI need a radical treatment by radical prostatectomy or radiation therapy. The forthcoming 2-3 years will show if new 1.5T platforms have the ability to consistently detect established ECE without the use of the endorectal coil. Intermediate or low risk tumors confined to the prostate or showing only a focal ECE may become in a short future candidates to focal treatments, aimed to ablate the tumor without exposing the patient to the potential severe side-effects of radical treatments. Currently, focal ECE can only be suspected by endorectal MRI and performance of MRI with an external coil only remains to be validated. However, it remains to be determined if detection of focal ECE is required in the perspective of a focal treatment which can provide a safety margin of approximately 2mm outside the capsule.

Sadhna Verma

Objectives: 1.Review the currently available prostate coils: endorectal, phased array and cardiac 2.Discuss the technical aspects of available coil options (ie coil channels) and magnetic field strength. 3.Discuss the technical aspects of performing a high quality prostate MRI for both cancer detection and staging.

LS2d 3T MRI for prostate - is it important? Valeria Panebianco, MD Sapienza University of Rome

Background: The prostate anatomic position allows a multiparametric approach to the study of the organ. All techniques from morphology to functional (T2w, DWI, MRS, MRP) can be performed thanks to its relative immobility. The aim of the Radiologists is to diagnose earlier the smaller significant lesion by using all the available tools.

Physical reasons: By definition and from the point of view of Physics a 3T magnet has an higher precession frequency than 1.5T; considering the Larmor equation - ω= γB0 – the precession frequency is directly proportional to the value of BO and so it is higher by using a superior field, respectively 63.9 MHz at 1.5 T and 127.8 MHz at 3T. Consequently the signal/noise (S/N) ratio improves and also in terms of spatial resolution (SNR), contrast resolution (CNR) and temporal resolution.

www.esur2013.org 36 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Advantages: The use of the 3T allows the use of higher b value, 2000 s/mm and more. Larger b-values are necessary to limit the effects of bulk motion (perfusion), consequently the advantages of using higher b-values include increase DWI.

At 3T more efficient MR Spectroscopy is obtained; also in this case we note the influence of B0 in the equation ω= γB0 (1-s), representative of Spectroscopy. It brings to better distinction of the metabolites compared to background and a serious of advantages in terms of peaks improvement, size voxel reduction and time acquisition (TA) reduction. The of use of 3T benefits also the MR Perfusion, due to the higher temporal resolution (up to < 5 sec), in order to obtain physiological modeling. An other advantage consists in the increased effect of gadolinium: an equivalent dose of gadolinium containing contrast agent causes an increased contrast difference at 3.0T with higher signal-to-noise and higher contrast-to-noise ratio.

Drowbacks: Ther’are some limits by using 3T magnet, first of all image distortion and artifacts at rectal wall- gas interfaces (endocoil positioned) and around metallic objects (in postoperative phase). In any case the advantages overcome the disadvantages at 3T; some are solvable.

Diagnostic and clinical impact: The optimization of all MR techniques offers the possibility to improve the quality of the images in order to detect smaller lesion (0.5 cc and less) and to better determine the aggressiveness of the tumor based on metabolism (MRS) and on the restriction of diffusivity of water molecules (DWI); also the characterization of the lesion based on vascularity (MRP) it can be evaluated. An early and correct lesion identification can finally reduce the negative biopsies; at the same time it’s possible to stage locally prostate cancer.

The early diagnosis of prostate cancer as well as a policy of screening can determine the following effects: increase in the diagnosis of cancers at an early nonmetastatic stage, increased therapeutic options, reduction of side effects from treatment, improvement in quality of life as well as improved cancer specific survival.

LS2e Controversies in Prostate Cancer Imaging” MR Spectroscopy - crucial for diagnosis or just a research tool? Geert Villeirs, Jelle Barentsz

PRO (Prof. G. Villeirs) MR Spectroscopy (MRS) provides information about the prostate metabolism by measuring the relative concentrations of metabolites such as citrate and choline. The complimentary changes of the latter metabolites are used to predict the presence or absence of prostate cancer, hence increasing both the sensitivity and specificity of MRI when used in combination with morphologic T2-weighted sequences. Its most important use, however, is in predicting the presence or absence of high-grade prostate cancer, defined as a primary Gleason score 4 or 5. A negative MRI+MRS in a patient with elevated PSA reduces the need for (re)biopsy, while a positive MRI+MRS identifies the region that should be targeted with a biopsy needle. MRS is also very helpful in delineating the tumor volume with highest Gleason grade for high-dose focusing in intensity-modulated radiotherapy. Furthermore, absence of significant metabolite peaks (“metabolic atrophy”) indicates absence of local recurrence after radiotherapy, which is particularly useful in reassuring patients with bouncing post-treatment PSA

CONTRA (Prof. J. Barentsz) The biggest challenge for prostate MRS, however, is to make it applicable for general practice. It should be simple, fast and good, with an easy learning curve. Unfortunately, one still needs to buy and use quite sophisticated software and experience to do the “reading”. It also is more time consuming, compared to the evaluation of T2W and DW images. Additionally, in the peripheral zone MRS is equal in detecting significant cancer compared to DWI. Only in the transition zone MRS is the best technique for this purpose, although the combination of T2W images and MR-guided biopsy offers an even better diagnosis. Nonetheless, MRS can be of benefit to the patient in equivocal lesions in the transition zone, being non-invasive. Prerequisite, however, is the development of fast and easy to control multi-parametric software and adequately trained technicians and radiologists.

37 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Lecture Session 3: Female Genital Tract Tumors Moderators: Teresa Margarida Cunha, Marta Heilburn

LS3a Ovarian cancer: Diagnosis, staging and predicting advanced disease Prof. Dr. Deniz Akata Hacettepe University Medical School Department of Radiology

Learning objectives: • To define the criteria for malignancy for ovarian masses with ultrasound and MR • To describe the MR technique for the ovary • To be able to understand the role of imaging in staging ovarian cancer and predicting advanced disease

Ovarian cancer is the fifth most common cause of death from cancer in women after lung, breast, colon, and pancreatic cancer. Although it is the second most common gynecological cancer, it is the deadliest form of gynecologic malignancy. Ovarian carcinoma is an insidious disease, and patients often present with an advanced (extrapelvic) stage of disease. The accurate detection and delineation and staging of gynecologic neoplasms remain one of the major challenges in oncological imaging. Although ultrasonography (US) is the initial imaging modality to evaluate the woman pelvis, magnetic resonance (MR) imaging and computed tomography (CT) are commonly used especially when neoplasm is concerned. US and MR imaging are mainly used to characterize the mass as benign or malignant. In pre treatment of these tumors the role of imaging is limited. Many gynecological surgeons rely on the findings of clinical and US examination and measurement of the serum CA-125 to make the diagnosis of ovarian cancer. Staging is almost always based on a formal staging laparatomy.

Tumor stage is a major factor in patient prognosis. The 5-year survival rate is 75-95% for stage I disease, 50% for stage II, 20-30% for stage III, and 5-8% for stage IV. Other prognostic factors include histologic grade, amount of residual disease after the initial cytoreductive surgery (debulking), and patient characteristics (age, performance status).

Surgery is the vital treatment for ovarian carcinoma. The goal of surgery is threefold: resection of the primary tumor with histologic confirmation of malignancy, accurate and complete staging, and optimal cytoreductive surgery (debulking). The amount of residual tumor after the initial debulking procedure is an important prognostic indicator for survival. In addition, debulking may greatly improve the patient’s quality of life. Debulking is considered optimal when residual tumor is less than 1.5–2.0 cm. The major benefit obtained from optimal cytoreductive surgery is improved response to chemotherapy. Generally, optimal resection of macroscopic disease is not possible in patients who have bulky disease in difficult-to-reach areas (porta hepatis, lesser sac, gastrosplenic and gastrohepatic ligaments, root of mesentery); extensive bladder, bowel, or sidewall invasion; or stage IV disease. Radiologic imaging has an important role in the identification of this group of patients, with accuracies of 93%–95% for both CT and MR imaging in the detection of unresectable disease.

Transvaginal ultrasonography (TVUS) is the most practical modality for assessment of ovarian tumors because it is readily available and has a high negative predictive value. It has a higher specificity in the diagnosis of ovarian cancer when compared to transabdominal US. Morphologic analysis of adnexal masses is accurate for identifying masses as either low risk or high risk. Morphologic features based on US findings including thick, irregular walls and septa, papillary projections, and solid, moderately echogenic loculi have been described as suggestive of malignant tumor. Color flow Doppler sonography has a complementary role in distinguishing benign lesions from malignant ones. If sonographic findings are indeterminate, MR imaging is the imaging of choice to characterize the mass due to its multiplanar capability, high spatial resolution and improved contrast resolution. The signal intensity characteristics of ovarian masses make possible a systematic approach to diagnosis. MR and US are both highly sensitive for characterization of malignancy but MR has a greater specificity than US at identifying malignant masses. The greater specificity of MR is due to its ability to characterize dermoid, endometriomas and fibromas which may appear malignant on US. CT is the most widely used modality for staging ovarian cancer or follow up of post surgical ovarian cancer patients. CT is useful for detecting tumour involvement of many intraabdominal and pelvic structures including; small and large bowel, urinary tract, peritoneum and mesentery, liver, lymph nodes, ascites and pseudomyxoma peritonea.

www.esur2013.org 38 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Functional imaging in the form of positron emission tomography (PET) combined with anatomic imaging CT can help identify patients with recurrent tumor by increasing radiologic sensitivity and specificity. The standardized uptake value (SUV) of FDG is not often used for diagnosis but is commonly used to follow up treatment response. SUVs tend to be higher in tumors than in benign lesions: the higher the SUV of a mass, the more likely the mass is to be malignant. The role of the radiologist is mainly to differentiate malignant ovariam mass from the benign one. Subsequent step is not to describe disease as resectable or nonresectable but instead to alert clinicians to the presence of disease that may complicate surgery or may preclude optimal debulking.

LS3b Functional Imaging in advanced disease of the uterus and cervix Corinne Balleyguier, Christine Haie-Meder, Catherine Uzan, Catherine Lhommé Uterine cervical cancer is the third most common gynaecological malignancy after endometrial and ovarian cancers. Nearly 80% of cervical cancer occurs in the developing countries and most patients are diagnosed with the disease at an advanced stage, thus not suitable for surgical staging. In June 2009, the FIGO committee introduced the revised staging of cervical carcinoma updating the previous staging of 1988. Although the revised FIGO staging system does not include imaging in the staging of cervical cancer, for the first time the committee encourages the use of imaging techniques, if available, to assess the important prognostic factors such as tumour size, parametrial and pelvic side wall invasion, adjacent organ invasion and the evaluation of lymph node metastases. Imaging is thus complementary to the clinical assessment with MRI being the optimal modality to stage cervical carcinoma FIGO stage 1B1 or greater. Morphological MR criteria are the most important criteria to assess tumor size and local invasion, with T2- weighted images. More and more, functional images on MRI may provide important information for cervical cancer staging and treatment evaluation. Perfusion imaging is one of the functional imaging tool which can be used. Addition of fast dynamic contrast- enhanced MRI significantly improved staging accuracy to 91%. The use of dynamic contrast-enhanced MRI also improves the accuracy of assessment of bladder and rectal wall invasion. Furthermore, the use of IV contrast medium is useful in the post-treatment setting to differentiate residual or recurrent tumour from radiation fibrosis. Perfusion imaging may also be used as a prognostic tool to evaluate radiation therapy. A low initial perfusion rate seems to be correlated to worse treatment response after chemoradiation therapy. Proportion of low perfusion regions in heterogenous tumour (10 % Si percentile) seems to be the best predictive criteria of local recurrence and overall survival. Particularly, a high perfusion tumour rate at 2.5 weeks is correlated to treatment response, and it seems there is a relationship between tumour vascularity, hypoxia and chemoradiation therapy response. Diffusion-weighted imaging is a second option in functional MRI for cervical cancer imaging, especially for treatment evaluation. The adjunct of DWI sequences after chemoradiation therapy may improve the differentiation between inflammatory changes and residual tumour, and may help to reduce the number of false positives. For endometrial cancer, routine use of dynamic intravenous contrast enhancement is necessary for state- of-the-art MR evaluation of endometrial carcinoma. DWI may have a special interest also. The use of a high b value makes images more sensitive to water diffusion; it thus increases contrast enhancement between normal and cancerous tissue, but this is offset by decreased signal intensity and anatomic detail in the adjacent structures. DWI can demonstrate uterine endometrial cancer and ADC measurement can provide useful information for differentiating malignant from benign uterine endometrial cavity lesions. Different reports showed significantly lower ADC value for endometrial cancer (0.86–0.98 x 10-3mm2/s) than that of the normal endometrium (1.53-1.65 x 10-3mm2/s). DWI performed with a parallel imaging technique provides valuable information for assessing myometrial invasion and should be considered as part of the routine preoperative MRI evaluation of endometrial cancer.

LS3c Challenging female pelvic tumor cases; mistakes I have made-I Andrea Rockall

LS3d Challenging female pelvic tumor cases mistakes I have made-II Rosemarie Forstner

39 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Lecture Session 4: Imaging of Urothelial Tumors Moderators: Nicolas Granier, Nevra Elmas

LS4a Imaging of urothelial tumors: the urologist’s perspective Fatih Atuğ

LS4b The upper urinary tract urothelial cancer Mustafa Ozmen

Transitional cell carcinoma (TCC) is the most common urothelial neoplasm to involve the upper urinary tract (UUT). Prognosis significantly worsens with deeper invasion. The role of imaging is to detect the tiniest urothelial neoplasms while still potentially resectable and curable. Imaging also has an important role in identifying synchronous or metachronous neoplastic lesions which is a distinctive feature of TCC. In case of advance disease, imaging will identify the extent of disease. Intravenous or retrograde urography, ultrasonography, computed tomography or magnetic resonance imaging have been used for diagnosis of UUT urothelial neoplasms. The diagnostic performances of these imaging modalities differ from each other. A recent review regarding imaging of TCC states that the retrieved sensitivity/specificity for the detection of upper urinary tract TCC for CT urography (CTU), MR urography, excretory urography, and retrograde urography were 96%/99%, 69%/97%, 80%/81%, and 96%/96%, respectively. It has been stated that CT urography is the best imaging technique for confirming or excluding malignancy in the upper urinary tract.

CTU is accepted as a gold standard for the diagnosis and staging of upper urinary tract TCC by European Association of Urology. UUT urothelial neoplasms commonly present as a single or multiple irregular filling defects on CTU. Focal urinary tract wall thickening with enhancement is another finding that can suggest the presence of urothelial neoplasm. The multicentric nature of TCC makes assessment of the entire urothelium essential before treatment. Vigilant urologic and radiologic follow-up is warranted to assess for metachronous lesions and recurrence. The emerging technique of CT urography not only detect the urothelial neoplasm but also plays an important role in the differential diagnosis, assessment of perirenal tissues, and staging of neoplastic lesions; thus it may offer the opportunity for one-stop evaluation in the initial assessment of hematuria and in follow-up of TCC.

LS4c Bladder Cancer Richard H. Cohan, M.D.

Introduction Although CT and MR urography (CTU and MRU) have now been used for over a decade, there has been only a minimal recent decrease in the number of patients presenting with advanced bladder cancer and only a minimal decrease in patient mortality [1]. To date, the emergence of these two techniques has had only minimal tangible effect on the management of patients with known or suspected bladder cancer: 1) to dramatically decrease or eliminate the performance of excretory urography, and 2) to obviate the need for flexible cystoscopy in patients in whom bladder abnormalities are detected on imaging studies. Nonetheless, an awareness of the appearance of bladder cancers on imaging studies, potential pitfalls, and potential effects upon patient management is important.

CTU technique While it has been stated that optimal CTU and MRU technique must include thin section axial and coronal or sagittal images obtained through the urinary tract after intravenously injected contrast material has been excreted into the bladder [2], recent studies have demonstrated that portal venous phase imaging is as accurate (possibly more accurate in detecting urothelial cancers [3]. To take advantages of the relative

www.esur2013.org 40 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY merits of both portal venous and excretory phase images, our current CTU protocol utilizes a single-bolus technique with the bladder imaged 70 seconds and 12 minutes after injection of 125 ml of 300 mg I/ml nonionic contrast material.

CT urographic appearance of bladder cancers in previously untreated patients On CTU and MRU, detectable bladder cancers produce: 1) asymmetric bladder wall thickening which may often appear mass-like, 2) tiny “filling defects”, or rarely 3) circumferential bladder wall thickening, with this last manifestation more commonly seen in patients with cystitis, neurogenic bladders, or outlet obstruction [2]. MRU appearances are similar.

False negative CTUs Although published studies report very high sensitivities of CTU (79-97%) and MRU in detecting bladder cancer [4-6], many bladder cancers can be missed on imaging studies. The lesions most likely to be undetected are those that are flat (carcinoma in situ), small (< 5mm), at the bladder base/neck, or in previously treated bladders [5, 6].

False positive CTUs False positive CTUs and MRUs are usually due to true abnormalities (due to benign disease) [7, 8]. Rarely, cystitis can produce focal bladder abnormalities that mimic small urothelial neoplasms. Other causes are benign neoplasms and post-treatment change [8].

Staging of bladder cancer CT and MR have limited utility in staging bladder cancers [9, 10], although MRU is likely superior (especially when contrast material is administered and diffusion weighted images are obtained [11]. Nonetheless, accuracy of both modalities is below 70%. [9-12]. Problems in staging relate to inability of CT and MR to determine depth of muscle invasion and the presence of microscopic perivesical or pelvic sidewall spread. Also, bladder cancers often spread to pelvic lymph nodes without enlarging them. Sometimes, accurate staging can be performed (for example when perivesical or pelvic organ invasion is gross or when metastatic lymph nodes are enlarged).

Role of CTU and MRU in patient management For above-mentioned reasons, the role of CT and MRI in evaluating patients with bladder cancer is still limited. However, some benefit has been identified. These studies can detect clinically unsuspected tumors in patients in whom cystoscopy is not planned. When performed in high-risk patients prior to cystoscopy, patients with an equivocal or positive finding can proceed directly to rigid cystoscopy. Initial flexible cystoscopy can be avoided with this approach in up to 17% of high-risk patients [13]. CT and MRI can also be used to confirm extravesical spread of tumor when spread is gross and to follow patients undergoing neoadjuvant chemotherapy.

Other imaging modalities for dection and staging of bladder cancer Ultrasonography can be used to detect bladder cancers. FDG PET has also been utilized primarily to follow patients with metastatic disease who are undergoing chemotherapy [14]. Unfortunately, both false negative and false positive PET examinations are encountered (the latter as a result of cystitis, for example), such that the role of FDG PET in bladder cancer is still uncertain [15]. Summary: is there a role for CTU in evaluating the bladder? Despite the ncreased sensitivity of the recently employed imaging modalities in detecting bladder cancer (compared with IVU), at the present time CTU and MRU cannot replace cystoscopy for assessment of patients with suspected or known bladder cancer. However, these studies can be used in lieu of flexible cystoscopy in some patients. Although MRI is superior to CT in staging of bladder cancers, both modalities have limited accuracy. Given these continuing limitations, there is an urgent need for further improvements in patient management.

References 1. Nieder AM, MacKinnon JA, Huang Y, et al. Florida bladder cancer trends: 1981-2004: minimal progressing in decreasing advanced disease. J Urol 2008; 179:491-495. 2. Cohan RH, Caoili EM, Cowan NC, et al. MDCT urography: exploring a new paradigm for imaging bladder cancer. AJR 2009; 192:1501-1508. 3. Mueller-Lisse UG, Mueller-Lisse UL, Hinterberger J, Schneede P, Meindl T, Reiser MF. Multidetector-

41 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY row computed tomography (MDCT) in patients with a history of previous urothelial cancer or painless macroscopic haematuria. Eur Radiol 2007;17; 2794-2803. 4. Sadow CA, Silverman SG, O’Leary MP, Signorovitch JE. Bladder cancer detection with CT urography in an academic medical center. Radiology 2008; 249:195-202. 5. Wang LJ, Wong YC, Ng KF, et al. Tumor characteristics of urothelial carcinoma on multidetector computerized tomography urography. J Urol 2010; 183:2154-2160. 6. Jinzaki M, Tanimoto A, Shinmoto H, et al. Detection of bladder tumors with dynamic contrast-enhanced MDCT. AJR 2007; 188:913-918. 7. Sudakoff GS, Dunn DP, Guralnick ML, et al. Multidetector computerized tomography urography as the primary imaging modality for detecting urinary tract neoplasms in patients with asymptomatic hematuria. J Urol. 2008; 179:862-867. 8. Ma W, Kang SK, Hricak H, et al. Imaging appearance of granulomatous disease after intravesical Bacille Calmette-Guerin (BCG) treatment of bladder carcinoma. AJR 2009; 192:1494-1500. 9. Vikram R, Sandler CM, Ng CS. Imaging and staging of transitional cell carcinoma: part 1, lower urinary tract. AJR 2009; 192:1481-1487. 10. Green DA, Durand M. Gumpeni N, et al. Magnetic resonance imaging in bladder cancer: current status and emerging techniques. BJU Int 2012; 110:1463-1470. 11. Watanabe H, Kanematsu M, Kondo H, et al. Preoperative T staging of urinary bladder cancer: does diffusion-weighted MRI have supplementary value. AJR 2009; 192:1361-1366.

LS4d Post-operative imaging V.Løgager

Genito-urinary surgery includes a wide range of techniques ranging from minimal invasion to wider resections. The invasive treatments include reconstructions due to congenital malformations, whole or partial resections and reconstructions when cancer is found. Staging includes lymphadenectomy which gives rise to specific changes and possible complications. Inflammation, abscesses or stones are also to be treated in various ways.

Complications are closely linked to the patient’s comorbidity.

Postoperative imaging deals with both early and late changes and controls after the treatment includes complications to the different treatments. It is therefore necessary to know normal postoperative imaging features and potential complications, knowing where and what to look for.

Most common complications are anastomotic leaks, hematomas, abscesses, lymphangiomas, fistulas, etc. To detect and monitor in most cases CT is the method of choice, ultrasound I often used to detect and treat whereas in patients with prostate cancer MR imaging is preferable.

It is always mandatory to have a full up to date patient record as well as previous imaging for comparison to ensure the most correct diagnosis. An overview of imaging techniques and the most common complications will be given, illustrated by clinical cases.

www.esur2013.org 42 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Lecture Session 5: Combined ESGAR Session Personalized treatment of abdominal tumors: General Principles Moderators: Michel Claudon, Luis Marti Bonmati

LS5a Future Developments in Imaging of Urothelial Carcinoma Maria Cova - Department of Radiology, University of Trieste, Italy

Urothelial tumors of the upper urinary tract (renal pelvis and ureters) are rare: the most common of these are transitional cell carcinomas (TCC), usually localized in the bladder (75% of the cases), whereas only 7-10% arise in the renal pelvis and 2.5-5% in the ureter. The presence of haematuria is a possible sign of urothelial malignancy, and this risk increases for men vs women, with advancing of age, and with macroscopic haematuria. Patients with microscopic haematuria have a relatively low risk of malignancy if young (<50 years for men and <60 years for women).

Current guidelines recommend careful investigation of haematuria. Although a precise consensus on the management of haematuria has not been reached yet, its evaluation constitutes an increasing workload for radiologist referred for urinary tract imaging. Most guidelines still recommend Intravenous Urography (IVU) as second line test, but its use has decreased in last decades, and now it has been completely substituted by Computed Tomography Urography (CTU). CTU is the imaging modality of choice for urinary tract malignancy detection. However CTU, especially when performed with a multiphase technique, is associated with high radiation doses, according to the published data as high as 10–35 mSv, depending on the number of phases, indication and technical parameters used. For this reason it is still important to investigate further techniques which can provide diagnostic effectiveness with no or less radiation exposure.

Magnetic Resonance Urography (MRU) is a promising technique for the study of the urinary tract, and it currently serves as an alternative imaging technique for children, pregnant women, and patients with a contraindication to iodinated contrast media administration. Nevertheless it has not been widely adopted in clinical practice.

MR urography can be performed by using heavily T2-weighted sequences without contrast material to image the urinary tract as a static collection of fluid (static-fluid MRU) or by using three dimensional T1 spoiled gradient echo (GE) sequences performed during the excretory phase after administration of gadolinium- based contrast material (excretory MRU).

Several studies have shown the potential of MRU in the evaluation of urinary tract diseases It represents an appealing alternative to CTU in haematuria evaluation thanks to the absence of radiation exposure and the possibility of urinary tract depiction without the use of contrast material in static-fluid sequences. Previous studies have demonstrated that MRU can recognize 74% of small non obstructing carcinoma and can detect neoplastic causes of urinary tract obstruction with an accuracy of 88%. A recent study suggests that CT urography provides a higher urothelial malignancy detection rate than MRU and so it has to be preferred for aged patients presenting with macroscopic haematuria, at high risk for malignancy, since its higher diagnostic performance certainly balanced the risk of radiation exposure. On the other hand MR urography is a useful imaging modality in the evaluation of patients with obstructed or poorly functioning kidney, regardless of the malignancy risk and potentially might have a role when investigating young patients with microhaematuria, at low risk for malignancy, in whom radiation exposure is an important limiting factor.

The higher accuracy of CTU compared to MRU in detecting urothelial carcinoma is due to some intrinsic limitations of MR imaging. First of all spatial resolution is lower than CT and thus millimetrical localization of transitional cell carcinoma could be missed. Moreover MRU is relatively insensitive to calcifications, with consequent poor diagnostic confidence in differentiating a stone from a neoplastic filling defect, unless contrast enhancement is demonstrated with other focussed sequences or the filling defect is not contiguous to urinary wall. Moreover the panoramic capabilities of CT allows diagnosis of both wall thickening malignancy and filling defects, while both static fluid and excretory sequences offer only lumen depiction. Lastly, it is more difficult to obtain diagnostic quality images with MR urography, when compared to CTU, particularly at calyceal level. Motion and breathing artifacts hamper urinary tract visualization, while also in

43 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY poorly cooperative patients CT imaging is of diagnostic quality.

Nevertheless CT urography, depending on contrast medium excretion, cannot depict urinary tract of obstructed patients, while dilated calyces and ureters are well delineated by static-fluid MRU, allowing to recognize not only the site of obstruction, where dynamic sequence could be focused, but also to exclude the presence of synchronous lesions.

Thanks to continued technologic developments, improvements in imaging of urothelial carcinoma will be achieved by developing CT urography techniques that result in lower radiation exposure and MRU techniques that result in faster imaging time while limiting the effects of respiratory motion, ureteral peristalsis and flowing urine, and in higher SNR and higher spatial resolution, leading to better image quality and increase in urotelial carcinoma detection. Technologic developments will also raise the potential of diffusion weighted imaging in the assessment of urothelial carcinoma.

LS5b Can we differentiate RCC subtypes with imaging? R. Oyen1, L. De Wever1, F. Claus1, E. Lerut2, H. Van Poppel3 Department of Radiology (1), Pathology (2) and Urology (3) University Hospitals Leuven, Department of Imaging and Pathology KU Leuven, Belgium (1,2) University Hospitals Leuven, Department of Development and Regeneration KU Leuven, Belgium (3)

According to the 1997 Heidelberg classification, the most common subtypes of RCC are clear cell, papillary and chromophobe carcinoma, accounting for approximately 90% - 95% of all malignant renal parenchymal epithelial tumors in adults. Benign oncocytomas can be mistaken for (clear cell) RCC at imaging, and oncocytomas account for 4% - 10% of nephrectomies in which RCC is suspected based on imaging. Each subtype of RCC is associated with a different prognosis, with clear cell RCC having the worst prognosis in both metastases rates and survival rates. Most incidentally detected RCCs are found during investigations for other medical conditions, and the overall survival rate is lower than expected, with comorbidity and mortality unrelated to RCC.

The prognosis of oncocytomas is considered excellent. Conservative treatment can be recommended and the importance of preoperative diagnosis is thus crucial.

For some reason, prediction of subtypes of RCC based on imaging data has become a diagnostic challenge for many (uro-) radiologists. However, the first question that needs to be addressed when facing a renal mass lesion rather than predicting a histological diagnosis, is whether the mass is a surgical lesion or a lesion for which treatment should/must be avoided.

Ultrasound has only limited sensitivity (>50% of lesions <3 cm diameter are missed) and specificity (no typical echogenicity, no characteristic features at color-Doppler, …). With experience, contrast-enhanced ultrasound (CEUS) may contribute to better characterization of renal masses. Heterogeneity on gray- scale, and contrast-enhanced ultrasound taking into account grade of contrast enhancement, quantitative measurement of peak intensity and lesion washout may be useful for differentiating clear cell carcinoma and non-clear cell tumors.

Although the value of CT in the evaluation of enhancing small solid renal lesions without fat remains controversial, a growing number of single-institution reports focus on specific contrast enhancement patterns at multiphasic CT for the prediction of histologic diagnosis of small renal masses. According to the most optimistic reports, multiphasic contrast-enhanced CT enables differentiating RCCs and oncocytoma, and even subtypes of RCCs, i.e. clear cell RCC from papillary RCC and chromophobe RCC. Nevertheless, the number of less optimistic studies is substantial, stating that a definitive diagnosis cannot be achieved by radiographic data alone before selecting a treatment (or not). Imaging guided biopsy is recommended for definitive diagnosis of small solid enhancing renal masses for further assessment of therapeutic management. This biopsy strategy is driven by the knowledge that approximately 20% - 50% of small renal masses removed by surgical excision have benign or relatively indolent pathology.

www.esur2013.org 44 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

In general, and oversimplified, the degree of contrast enhancement at multiphasic CT of clear cell RCC is greater than that of other RCC subtypes. Yet there is a wide overlap with the enhancement features of oncocytomas.

Some studies suggest that segmental enhancement inversion during corticomedullary phase and early excretory phase CT is a characteristic enhancement pattern of small renal oncocytoma and may help in reliably differentiating small oncocytoma from RCC, thus contributing to treatment decisions. Other studies, however, could not confirm segmental enhancement inversion to be a common (rather infrequent !) or characteristic CT finding for renal oncocytoma and, therefore, enhancement inversion was not a useful feature in differentiating small renal oncocytomas from RCC.

It seems that with growing experience, and with using advanced MRI-techniques, MRI provides important information to the diagnosis of subtypes of RCC. On MRI, the absence of central area signal intensity inversion or presence of a signal drop on chemical-shift imaging may rule out the diagnosis of oncocytoma. DWI-MR has potential and additional value by allowing differentiating benign from malignant renal masses, and subtyping of renal cell carcinoma.

References:

F. Agnello et al. Small solid renal masses: characterization by diffusion-weighted MRI at 3 T. Clin Radiol 2013;68:301-308 V.G. Bird et al. Differentiation of oncocytoma and renal cell carcinoma in small renal masses (<4 cm): the role of 4-phase computerized tomography. World J Urol 2011:29:787-792 J.C. Cheville et al. Comparisons of outcome and prognostic features among hitologic subtypes of renal cell carcinoma. Am J Surg Pathol 2003; 27(5):612-624 F. Cornelis et al. Combined late Gadolinium-enhanced and double-echo chemical-shift MRI help to differentiate renal oncocytomas with high central T2 signal intensity from renal cell carcinomas. AJR 2013;200:830-838 K. Dodelzon et al. Prediction of growth rate of solid renal masses: utility of MR imaging features – Preliminary experience. Radiology 2012;262:884-893 I. Frank et al. Solid renal tumors: an analysis of pathological features related to tumor size. J Urol 2003;170:2217-2220 S. Gerst et al. Evaluation of renal masses with contrast-enhanced ultrasound: initial experience. AJR 2011197:897-906 S. Gürel et al. Subtypes of renal cell carcinoma: MRI and pathological features. Diagn Interv Radiol 2013;19:304-311 J.H. Kom et al. Predicting the histology of small renal masses using preoperative dynamic contrast-enhanced magnetic resonance imaging. Urology 2012;80:872-876 J.I. Kim et al. Segmental enhancement inversion at biphasic multiditector CT: characteristic finding of small renal oncocytoma. Radiology 2009;252:441-448 E. Inci et al. Diffusion-weighted magnetic resonance imaging in evaluation of primary solid and cystic renal masses using the Bosniak classification. European Journal of Radiology 2012;81:815-820 G. Kovacs et al. The Heidelberg classification of renal cell tumours. J Pathol 1997;183(2):131-133 J.P. McGahan et al. Is segmental enhancement inversion on enhanced biphasic MDCT a reliable sign for the noninvasive diagnosis or renal oncocytomas ? AJR 2011;197:916 M.E. O’Malley et al. Small renal oncoctymas: is segmental enhancement inversion a characteristic finding at biphasic MDCT? AJR 2012;199:1312-1315 I. Millet et al. Characterization of small solid renal lesions: Can benign and malignant tumors be differentiated with CT? AJR 2011;197:887-896 M. Nguyen et al. The evolving presentation of renal carcinoma in the United States: trends form the Surveillance, Epidemeiology and End Reuslts program. J Urol 2006;176:2397-2400 P.M. Pierorazio et al. Multiphasic enhancement patterns of small renal masses (≤4 cm) on preoperative computed tomography: utility for distinguishing subtypes of renal cell carcinoma, angiomyolipoma, and oncocytoma. Urology 2013;81:1265-1272 K.E. Sand et al. Incidentally detected renal cell carcinma are highly associated with comorbidity and mortality unrelated to renal cell carcinoma. Scandinavian Journla of Urology 2013; Early Online, 1-10 K. Sandrasegaran et al. Usefulness of diffusion-weighted imaging in the evaluation of renal masses. AJR 2010;194:438-445

45 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

E. Squillaci et al. Correlation of diffusion-weighted MR imaging with cellularity of renal tumors. Anticancer Research 2004;24:4175-4180 L.D. Truong et al. Immunohistochemical diagnosis of renal neoplasms. Arch Pathol Lab Med 2011;135(1):92- 109 H. Wang et al. renal cell carcinoma: diffusion weighted MR imaging for subtype differentiation at 3.0 T. Radiology 2010;257:135-143 S. Woo et al. Segmental enhancement inversion of small renal oncocytoma: Differences in prevalence according to tumor size. AJR 2013;200:1054-1059 J.R. Young et al. Clear cell renal cell carcinoma: discrimination from other renal cell carcinoma subtypes and oncocytoma at multiphasic multidetector CT. Radiology 20.13;267:444-453

LS5c Vascular Anomalies of the Liver: a roadmap to imaging diagnosis F Caseiro-Alves, Imaging Department, University Hospital Centre of Coimbra, Portugal

The dual blood supply of the liver together with the possibility to recruit functional arterio-portal shunts at the parenchymal microstructure level creates a unique challenge to modern cross-sectional imaging since both disease, pitfalls and normal variants can behave similarly and do need to be differentiated. Furthermore, vascular changes act as a potential stimulus for the development of hypervascular nodules that will share many of the imaging features of both benign and malignant conditions such as FNH or HCC. Vascular changes can be sub-divided according to the level of the original insult in portal venous outflow obstruction, venous outflow obstruction, vascular shunting or those related to anatomic variants. Portal flow obstruction can occur at a central level due to thrombosis and/or cavernomatous transformation of the portal trunk or its major branches or at a more peripheral intra-hepatic level. If the first situation is easily diagnosed by its direct (thrombosis) and indirect signs (THID), the second situation may be more elusive as it is the case of the recently described obliterative portal venopathy, also called hepatoportal sclerosis. From the hepatic venous side Budd-Chiari syndrome and the sinusoidal obstruction syndrome (SOS), apart from their own imaging signs, share the possibility of developing hypervascular nodules, presumably representing an hyperplastic response to hypoxia ending up in the identification of single or multiple multiacinar nodular regenerative hyperplasia (mNRH). This may happen once the chronic phase of the vascular insult will begin to be established.

Vascular shunting, can be found at different levels establishing arterio-venous, portal-venous or veno- venous communications can on its own simulate neoplasms and one of its greatest challenges consists in differentiation from true hypervascular nodules especially in the context of liver cirrhosis. When congenital and/or sufficiently large, these shunts can deviate all or the majority of the portal venous blood away from the liver, establishing porto-systemic comunications. Again, the net result will be the development of parenchymal hypoxia, that concurrently with other factors, will promote the development of mNRH, as seen in the pediatric or young adult ages in cases of porto-systemic shunts.

Vascular variants, consisting in specific pathways of congenital shunting, do have foreseeable imaging findings that should be known. The typical example is represented by the so called third inflow tracts to the liver, as it is the case of aberrant left gastric vein drainage abutting directly into the liver parenchyma and causing a pseudo-tumoral perfusion abnormality located along the hilar side of segment IV.

In summary, liver vascular diseases and variants represent a clear cut group of imaging findings ranging from simple perfusion abnormalities to the development of hypervascular nodules. A note of caution must be made since even well identified by any cross-sectional imaging modality, one should keep in mind that they represent a vast array of different pathological conditions from congenital to acquired diseases such as liver cirrhosis, coagulopathies, drug toxicity or immune diseases. This is the reason why their prompt recognition and clinical integration are of utmost importance for patient management.

www.esur2013.org 46 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

LS5d MR Imaging biomarkers in rectal cancer Andrea Laghi - Department of Radiological Sciences, Oncology and Pathology Sapienza - Università di Roma

Neoadjuvant preoperative chemo-radiotherapy (CRT) and radical surgery (Total Mesorectal Excision) has become the standard treatment for locally advanced rectal cancer. However, this therapeutic approach needs robust staging and re-staging techniques in order to avoid over- or under-treatment of different sub-groups of Patients. Magnetic Resonance Imaging (MRI) is the gold standard for pre-operative staging of rectal cancer, but the reported evidence on the role of MRI in assessing response to therapy (re-staging) based only on morphological evaluation has been shown presenting several limitations. Hence the reason for investigating novel MR imaging quantitative biomarkers, able to establish more objectively the response to therapy and to identify non-responders immediately after the start of neo-adjuvant treatment. Different MR imaging biomarkers have been identified in oncologic imaging: a) Texture analysis (TA) of morphological T2 weighted images; b) Diffusion-Weighted Imaging (DWI); c) Intravoxel incoherent motion (IVIM) and d) perfusion MRI (pMRI). a) Texture analysis is non-invasive method of assessing the heterogeneity within a tumor. Tumors with high intratumoral heterogeneity have been shown to have poorer prognosis, which could be secondary to intrinsic aggressive biology or treatment resistance. Different methods exist, including statistical-, model-, and transform-based methods. To date, studies that have been performed have focused in several areas, where the addition of texture to current methods may improve the detection, diagnosis, characterization, and response assessment. By highlighting certain features within a lesion of interest, texture analysis has the ability to improve assessment beyond direct visual analysis by a radiologist b) Diffusion weighted imaging (DWI) is a diagnostic technique based on the measurement of Brownian motion of water molecules in tissues, which is different according to tissue characteristics. The apparent diffusion coefficient (ADC), a quantitative parameter measured on DWI, has been suggested to provide useful information regarding tumor cellularity, tumor aggressiveness, subtype characterization, and cancer treatment response. To date, in rectal cancer assessment, there is no demonstrated benefit of the use of DWI at primary staging, but there is growing evidence that the use of DWI in association with morphological T2 weighted sequences improves the performance of MRI in the assessment of tumor response after CRT and might be helpful in predicting responders versus non-responders. However, no consensus exists on the additional value of DWI for the assessment of a complete tumor response after CRT. Preliminary experimental evidences suggest that pre-CRT ADC in responders is significantly lower than that in non-responders and moreover a significant increase of the mean ADC after neoadjuvant CRT occur in the responder group with locally advanced rectal cancer. Lower ADC values were associated with a more aggressive tumor profile and ADC has the potential to become an imaging biomarker of tumor aggressiveness profile. c) Intravoxel incoherent motion (IVIM) is an advanced analysis of DWI based on the acquisition of multiple diffusion b values. It represents a novel imaging approach in abdominal tumors, never being tested up to date in rectal cancer. Advanced analysis permits to evaluate microscopic movements in biologic tissues, including diffusion of water molecules and microcirculation of blood (perfusion). IVIMs are quantified by means of the apparent diffusion coefficient (ADC). ADC incorporates the effects of both diffusion and perfusion and is equal to the true diffusion coefficient D when diffusion is the only type of present motion. Perfusion fraction is strictly related to tissue vascularization. The possibility to accurately calculate this parameter could enable a non invasive evaluation of tumor perfusion. Perfusion parameters derived from IVIM modeling have been proposed as potential biomarkers of tumor vascularization. Indeed, the exact nature of what is measured with IVIM MR imaging deserves further investigation. d) Perfusion MRI (pMRI) offers the possibility to analyze real tumor perfusion after contrast medium (Gadolinium chelate) administration. Perfusion MRI is an imaging modality that relies on the dynamic assessment of tracer uptake kinetics, subsequently quantified by means of pharmacokinetic models. These models describe, in terms of pharmacokinetic parameters, the wash-in and wash-out of contrast agent from the microvasculature into the surrounding tissues. Using a two-compartmental model Ktrans (wash-in rate), Kep (wash-out rate), Ve (extravascular extracellular space volume) and IAUGC90 (initial area under the gadolinium contrast agent concentration time curve at 90s) can be calculated. A preliminary study on a small cohort of patients has recently demonstrated a correlation between tumor response and Ktrans in tumor treated with antiangiogenetic drugs (Anti-VEGF, vascular endothelial growth factor). However, this data are limited to patients treated with experimental drugs and no data are currently available for tumors treated with classical neo-adjuvant CHT protocol.

47 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Lecture Session 6: SAR HONORARY LECTURE Moderators: Ahmet Tuncay Turgut, Michael Claudon

LS6a New Horizons in Prostate imaging Vikram Dogra

www.esur2013.org 48 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Lecture Session 7: Contrast Agents and Safety Moderators: James Ellis, Jarl Jakobsen

LS7a Kidney function - eGFR, questionnaire etc. Georg Bongartz MD University Hospital Basel, Switzerland

Because of the nephrotoxicity of iodine-based contrast media and the more recently accepted role of gadolinium-based contrast media in the etiology of nephrogenic systemic fibrosis, the renal function of patients undergoing contrast enhanced imaging studies must be known prior to the respective investigation so that, if necessary, appropriate preventive measures can be taken. The risk of these two adverse reactions increases with decreasing glomerular filtration rate, which cannot be measured directly. Uncertainties exist about the estimation of renal function by various tests and also about the exact meaning of clearance, and its relationship to eGFR. To date,laboratory testing of serum creatinine with calculation (estimation) of the glomerular filtration rate is used to identify at-risk patients. The various alternative methods for measuring renal function using laboratory tests and the various equations for estimating glomerular filtration rate are reviewed, and the possible value of questionnaires to replace serum creatinine measurement are discussed. The latter may mainly be applied in outpatients at low risk for CIN or NSF.

LS7b Contrast Media and the Kidney Professor Sameh K Morcos, Emeritus Professor of Diagnostic Imaging University of Sheffield, Sheffield, UK

The contentious issues concerning the prevention of contrast induced nephropathy (CIN) will be discussed. The current consensus on the best approach to reduce the risk of this complication is the use of the lowest possible dose of either low or iso-osmolar contrast agent and adequate volume expansion with either normal saline or sodium bicarbonate. The guidelines of the European Society of Urogenital Radiology (ESUR) on the use of metformin and iodine based contrast media will be presented. The safety of using either iodine based or gadolinium based contrast agents (GBCA) in patients with advanced renal impairment will be discussed. In this group of patients it is safer to use the highly stable macrocyclic GBCA than using iodine based contrast media (ICM) as the complication of nephrogenic systemic fibrosis is very rare with these highly stable agents. On the other hand, all ICM have the potential of inducing CIN and thus enhance the progression of renal impairment to become dialysis dependent.

LS7c Acute non-renal adverse reactions: is it always an adverse reaction? Marie-France Bellin University hospital Bicêtre-P. Brousse University Paris Sud, France

With increased utilization in recent years of CT and MR to evaluate outpatients, inpatients and emergency room patients, the likelihood of encountering a patient having an adverse reaction to contrast media has increased. Acute reactions are classified into acute and delayed reactions. By definition, acute reactions occur within an hour following contrast administration. They are further subclassified into mild, moderate (or intermediate), and severe reactions. They are summarized in the below Table:

Mild Moderate Severe Nausea Severe vomiting Pulmonary oedema Vomiting Extensive urticaria Severe laryngeal oedema Headache Laryngeal oedema Severe cardiac arrhythmias Flushing Dyspnea (bronchospasm) Cardiac arrest Pruritus Hypotension Convulsions Limited urticaria Circulatory collapse Arm pain Unconsciousness Mild pallor

49 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Mild reactions are of short duration, self limiting, and do not require specific treatment. Moderate and severe reactions represent serious degrees of reaction that need immediate management. Moderate reactions usually respond readily to appropriate therapy, while severe reactions are life-threatening.

Incidence The incidences vary a lot from study to study, and most studies do not –with 2 exceptions- include a control group. The circumstances (retrospective vs prospective study, active interview, structured questionnaire or simple question), and the Lalli and Weber effects (1), probably explain partly the variations. In addition, adverse events have been reported after unenhanced CT or MR. In 2006, Schild et al. (2) reported in a large prospective randomized study that acute non-renal adverse reactions seen in the group administered with contrast medium also occurred in the control group undergoing the same unenhanced imaging examination. A recent, large, and prospective study evaluated the true incidence of acute non-renal reactions to enhanced MR and CT compared to control groups (3). It showed that acute adverse reactions were significantly more frequent (p<.05) in the contrast enhanced MR (18.5%) and CT (7.7%) groups compared to unenhanced MR (9.0%) and CT (2.3%) groups. Dizziness was significantly (7.3%, p<.05) more frequent in the enhanced MR group. With one exception, all reported adverse events were classified as mild.

In the literature (4), mild adverse reactions to iodinated contrast media are seen in as many as 15% of patients receiving high-osmolality ionic contrast agents and up to 3% of patients receiving low-osmolality agents. Severe and very severe reactions have been reported much less frequently, with respective incidences of 0.22% and 0.04% in patients receiving high-osmolality agents and 0.04% and 0.004% in patients receiving low-osmolality contrast media intravenously. Fatal reactions are exceedingly rare with both types of contrast media (1:170,000); there is no difference in associated mortality between the two types.

Predisposing factors Patients at high risk of these reactions should be identified before contrast administration to ensure that all necessary measures to reduce the risk are taken. Risk factors for acute non-renal reactions include (4):

• previous generalized contrast medium reaction, either moderate (e.g. urticaria, bronchospasm, moderate hypotension) or severe (e.g. convulsions, severe bronchospasm, pulmonary edema, cardiovascular collapse) • asthma • allergy requiring medical treatment • the use of high osmolality ionic contrast media.

There is a six fold increase in incidence of severe reactions to both ionic and non-ionic iodinated contrast agents in patients with a history of previous severe adverse reaction to contrast agents. Asthma is also an important risk factor with reported six-to tenfold increase in the risk of a severe reaction in such patients. A strong history of allergy requiring treatment increases the incidence of severe reactions by a factor of 3.

Mechanism Although the mechanism by which reactions occur is still unclear, thereby making prevention of reactions more difficult, it probably involves true allergic hypersensitivity and direct chemotoxicity related to the nature of the contrast medium, as well as the dose and osmolality of the contrast agent. A recent experimental study documented the role of mediators such as histamine and nitric oxide which are released during anaphylactic shock and which may contribute to vasodilatation (25-fold increase in capillary permeability within minutes of the onset of anaphylactic shock) and subsequent hypotension (5).

Acute non-renal reactions to gadolinium-based contrast agents The reported frequencies range from 0.017% to 2.4%, but rates as high as 18.4% (3, 6, 7) have been recorded. Most acute adverse reactions are mild and transient. They are the same as the ones seen with iodinated contrast media. Risk factors for acute reactions include a history of allergy, bronchial asthma or previous reaction to gadolinium-based contrast media.

In conclusion: The fact that the same acute non-renal reactions are seen in both after contrast and no contrast medium administration raises the question whether a mild reaction after exposure to contrast medium should be classified as a reaction to the contrast medium an all situations. The radiologist should weigh the possible clinical benefits to the at-risk patient from a contrast-enhanced imaging study against the small, but ever-present risk of contrast media reaction before administration of contrast.

www.esur2013.org 50 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

References

1. Thomsen HS, Webb J. The Lalli and Weber effects and the incidence of acute non-renal adverse reactions to contrast media. Acta Radiologica 2012; 53: 953-954 2. Schild HH, Kuhl CK, Hübner-Steiner U, et al. Adverse events after unenhanced and monomeric and dimeric contrast-enhanced CT: a prospective randomized controlled trial. Radiology 2006; 240:56-64 3. Azzouz M, Romsing J, Thomsen HS. Acute non-renal adverse reactions after unenhanced and enhanced CT and MR. OJCD in press 4. Morcos SK, Thomsen HS. Adverse reactions to iodinated contrast media. Eur Radiol 2001; 11:1267-1275 5. Faye N, Fournier L, Balvay D, et al. Macromolecular capillary leakage is involved in the onset of anaphylactic hypotension. Anesthesiology. 2012; 117:1072-1079 6. Abujudeh HH, Kosaraju VK, Kaewlai R. Acute adverse reactions to gadopentetate dimeglumine and gadobenate dimeglumine: experience with 32,659 injections. AJR Am J Roentgenol 2010; 194: 430-434 7. Kirchin MA, Pirovano G, Venetianer C, Spinazzi A. Safety assessment of gadobenate dimeglumine (MutiHance): extended clinical experience from phase I studies to post-marketing surveillance. J Magn Reson Imaging 2001; 14: 281-294

LS7d Nephrogenic systemic fibrosis - 7 years on Henrik S. Thomsen

51 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Lecture Session 8: Pediatric Urogenital Imaging Moderators: Michael Riccabona, Ulrich Willi

LS8a Pitfalls in imaging urogenital masses during childhood: case based demonstration of common problems - how to image, who they look, what to look for, and differences from common approaches in adults Ulrich Willi

LS8b Impact of recommendations and guidelines on clinical practice - does it matter at all? Results of an European questionnaire. Riccabona Michael, Graz

Objective: Huge efforts are undertaken to create imaging guidelines and recommendations particularly from the ESUR. However, little is known about the impact of these measures on patient management. Therefore the ESUR Pediatric Working Group and ESPR Uroradiology Task Force set out to evaluate if existing procedural and imaging recommendations in pediatric uroradiology have improved imaging in terms of reducing patient burden, particularly by irradiating investigations, by providing a proposal for standardised imaging and imaging algorithms.

Method: A questionnaire was sent by e-mail to ESPR and GPR members asking recipients to subjectively report knowledge, adherence to, and impact of the existing ten pediatric procedural recommendations and eleven proposals for imaging algorithms in pediatric uroradiology.

Results: From approximately 700 recipients 67 answers were received between October 2012 und March 2013 via fax or e-mail and Monkey Survey. Answers came from throughout Europe and also from Canada, USA and other, particularly Arabian and Asian countries. It appears that within pediatric radiology those recommendations are well known - mostly from meetings, internet and literature; some from personal visits and individual communications. Awareness is high in the pediatric radiology field and low in clinicians. Adherence varies; most people only partially adhere to the recommendations, even if they are known. Again, clinicians are those who have the least adherence to these proposals and consecutively do not think that they have impacted clinical practice and patient management. In terms of adequacy, pediatric radiologists consider the recommendations very useful and helpful, having changed their approach and disease understanding. Again, in general radiology and particularly with clinical colleagues less impact was observed. The last survey question asking about the need for update shows that the majority does not deem revisions necessary.

Conclusion: The existing recommendations on pediatric uroradiology imaging are known to most pediatric radiologists, less to general radiologists and at least to clinicians. This implies the need of enhancing communication with clinicians, trying not only to increase awareness of existing recommendations and the rationale behind these approaches, but also to discuss applicability and eventually feeding back these aspects to enable a respective update of those recommendations with a wider acceptance. Furthermore, pediatric radiologists need to engage in multi-disciplinary teams who create clinical guidelines so that the pediatric radiology recommendations eventually will impact those guidelines which are most commonly used by clinicians.

LS8c Contrast-enhanced Ultrasonography (CEUS) of the child’s urinary tract: revisited Frederica Papadopoulou, Aikaterini Ntoulia, Michael Riccabona, Kassa Darge.

Contrast-enhanced ultrasonography (CEUS) is a radiation-free imaging-modality performed with ultrasound- contrast-agents (UCAs) administered intracavitary or intravenously (IV). The most widely used UCAs are So- noVue® in Europe and Optison® in the USA. Both are second-generation UCAs comprised of gas-filled-micro- bubbles authorized for clinical-use in adults, but not in children. The most common application of CEUS is the contrast-enhanced-voiding-urosonography (ce-VUS). IV CEUS in children is much less widespread.

www.esur2013.org 52 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Contrast-enhanced voiding urosonography Ce-VUS emerged as a-non-ionizing imaging-modality for detection and follow-up of vesicoureteral-reflux (VUR) in children. It entails bladder-catheterization and intravesical-UCA-administration. The ESPR uroradiology- task-force and ESUR pediatric-work-group has issued procedural recommendations for ce-VUS performance with the previously available first-generation UCA Levovist®. The same procedural guidelines are updated for the current UCA SonoVue® with the important addition of urethral imaging. The use of high-resolution linear or multifrequency convex transducers and transperineal approach during voiding enables excellent visualization of urethral-lumen-morphology by the presence of the echogenic UCA. As a result urethra related pathology can be detected with high reliability in boys and girls such as: posterior urethral valves, anterior-urethra and prostatic-utricle diverticula, as well as congenital stenosis of the bulbar urethra.

Ce-VUS diagnostic efficacy: A recent meta-analysis of the existing literature demonstrated the high diagnostic efficacy of ce-VUS com- pared to its ionizing counterparts namely voiding cystourethrography (VCUG) and direct radionuclide cystog- raphy (DRNC). In total 29 studies including 2549 children were analyzed. Ce-VUS performance with the use of SonoVue® and Levovist® was compared to VCUG with an overall sensitivity and specificity 90% and 92% respectively. Compared to DRNC the sensitivity and specificity were 94% and 95% respectively. The sensitivity of ce-VUS with SonoVue® was better than with Levovist® (92% versus 90% respectively).

Ce-VUS safety issues: Recently a survey among European radiologic institutions, undertaken by the ESPR Uroradiology Task Force together with the ESUR Pediatric Working Group, showed ce-VUS with SonoVue® performed in a total of 4131 children, mean age 2.9 years, with no adverse events attributed to it. Earlier, six comparative studies between ce-VUS with SonoVue® and VCUG were conducted and no adverse event was reported. Recently, a study in 1010 children, mean age 2 years, prospectively evaluated for the incidence, nature and duration of possible ad- verse events after ce-VUS with SonoVue®. In this study 37 children (3.7%) were reported to experience some kind of post- procedural adverse event, with the most frequent being dysuria (n=26/37). Similar adverse events were previously reported in children who underwent VCUG, radionuclide cystography (RNC) and diuretic renal scintigraphy (DRS) after bladder catheterization, attributed to the catheterization itself rather than the use or type of the contrast material administered in the bladder.

Contrast-enhanced genitography In urogenital congenital anomalies a multi-modality imaging-approach is usually required, including US, VCUG, contrast-vaginogram, contrast-enema and magnetic-resonance imaging. Recently, ce-US genitogra- phy was introduced as useful application in the evaluation of urogenital-tract-abnormalities, such as Mülleri- an-duct anomalies, cloacal malformations, urogenital sinus, vaginal obstructions, as well as in the diagnostic work up of ambiguous genitalia. It is performed with US and intracavitary administration of saline, comple- mented by UCA-administration. There are not sufficient studies to comment on the diagnostic efficacy and safety of ce-US genitography. There is only one case report with the use of Levovist®.

IV CEUS of the urinary tract in children The IV CEUS in children is much less widespread compared to the intravesical. The European survey re- vealed 948 IV CEUS examinations with SonoVue® from 33 centers (mean-age 5 years). The most common indications were tumors, trauma, inflammation, renal transplant, renal infection, infarction and guided interven- tional procedures (percutaneous nephrostomy).

IV CEUS for kidney evaluation after abdominal trauma IV CEUS has an important role in the imaging of trauma patients. It can be performed as bed-side examina- tion, in haemodynamically-stable patients, with minimal-to-moderate low-energy trauma, along with contrast- enhanced-CT as initial examination and/or as follow-up examination of known injuries treated conservatively. IV CEUS can also be proved useful in the diagnostic work-up of trauma-patients with negative baseline-US and persistent clinical and/or laboratory suspicion. In the context of abdominal evaluation, a total of two UCA’s doses can be used, one for each abdominal side, with repeated dose if required. In each side, kidney is the first-organ to be examined immediately following UCA-administration. IV CEUS can accurately define the location, size of renal-parenchymal lesions (contusions, lacerations and hematomas), and their extension to organ-capsule. Moreover assessment of renal-parenchymal-perfusion in the setting of renal-vessel injuries and presence of active hemorrhage provide important information for further patient’s management.

53 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

IV CEUS diagnostic efficacy: Comparative studies after IV CEUS in children are limited. In a recent literature-review of 32 studies on pe- diatric applications of IV CEUS with SonoVue®, six studies were performed for post-traumatic evaluation of abdominal organs, and high diagnostic performance of IV CEUS in the diagnosis of such lesions was reported. Only one study included exclusively children and the sensitivity and specificity of IV CEUS were 92.9% and 100% respectively. Regarding renal injuries detection there was complete agreement between CEUS and contrast-enhanced CT although only one renal-injury was included.

A multi-centric European prospective study including 156 trauma patients, both children and adults, demon- strated high diagnostic accuracy of CEUS compared to gold-standard contrast-enhanced-CT, with sensitivity and specificity for renal-lesion-detection 69% and 99% respectively. In this study, 19/26 renal injuries were correctly identified by CEUS. The few missed minor-lesions did not affect patients’ management or overall prognosis.

IV CEUS safety issues: Regarding the incidence of adverse reactions after IV SonoVue® administration, the European survey re- vealed five children to experience minor side-effects (urticaria, rash, unusual taste and hyperventilation). Regarding Optison® administration two children were reported to experience tinnitus, light headedness and taste alteration which resolved within minutes.

Conclusions: CEUS is increasingly used in several established or developing applications. Several factors contribute in CEUS gaining-role in diagnostic practice such-as the absence of radiation-exposure coupled with its high- diagnostic efficacy. Moreover the lack of sedation, allowing for quick and bedside performance, are additional advantages. Currently the only limitation is the off-label use of UCAs, despite that no serious adverse-events are reported.

LS8d News from the ESPR Pediatric Uroradiology Task Force and ESUR Pediatric Working Group Riccabona Michael, Graz

Due to a lower number of active members, the ESUR Pediatric Working Group has presently sustained her activities; however, ongoing work is being performed in the related ESPR Uroradiology Task Force. The present achievements and projects have the same objective as previously, i.e., trying to improve imaging in pediatric uroradiology by reducing invasiveness and improving standardization, possibly helping to create comparable results for future studies that may establish more evidence. Recent accomplishments are publication of the latest version of our recommendations (on childhood renal biopsy, imaging the neonatal female genitalia, and contrast-enhanced ultrasound in pediatric = CEUS uroradiology) in Paediatr Radiol. Furthermore, dedicated papers on specific topics have been published: on paediatric urinary tract CT in Eur J Radiol , on childhood cystic renal disease in Am J Roentgenol, and on pediatric renal transplant imaging (submitted). Furthermore the ESUR Working Group and ESPR Task Force have contributed to the new ESUR contrast guideline book by writing the pediatric chapter.

Ongoing projects try to improve and standardize terminology in pediatric uroradiology by harmonizing and defining terms helping to avoid misunderstandings. Furthermore an update paper on CEUS in the child’s urinary tract is being pursued, helping to promote pediatric CEUS even if it will remain an off-label application. The impact of the till now published 21 recommendations (all of them are now free excess papers in Pediatr Radiol) has been evaluated by a questionnaire; the results and conclusions are presented in this meeting.

Future projects address imaging in intersex, standardization of urethrography, recommendation on imaging pediatric testicular or ovarian torsion, and hopefully cooperative research, for example on the development of pelvi-ureteric junction obstruction etc.

In conclusion: Even though the ESUR Work Group has presently sustained its work, ongoing activities of the related ESPR Uroradiology Task Force will feed into the ESUR Working Group and help maintaining a high level performance in the pediatric uroradiology field - though with a slight shift of main intention.

www.esur2013.org 54 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

LS8e Paediatric genital & pelvic tumors: imaging approach, differential diagnosis, typical examples Prof. Dr. Mithat Haliloğlu

Definitive diagnosis of pediatric pelvic neoplasms depends on a multidisciplinary approach and teamwork involving pediatricians, pediatric oncologists, pediatric radiologists, and pathologists. Radiological studies, in the context of clinical history, often aid to define the pattern of involvement and limit the differential diagnosis. Ultrasonography (US), which is a safe and available modality providing real-time images of multiple planes is the initial modality of choice in general, followed by computed tomography (CT) useful to stage the disease, but has the disadvantage of ionizing radiation. Magnetic resonance (MR) imaging may be used for staging and as a problem-solving technique in selected patients, however need for sedation and anesthesia should also be considered in the pediatric age group.

The aim of this presentation is to share a flavor of patients with typical pelvic masses in childhood period, and discuss differential diagnosis based on individualized imaging modalities.

Ovarian tumors in childhood are mostly benign (teratomas, cystadenomas), only 1/3 of the neoplasms are malignant (germ cell tumors, sex cord-stromal tumors, epithelial tumors) in nature. Imaging findings are nonspecific, and therefore it is difficult to differentiate from one another based on imaging features. Age of onset, clinical symptoms, laboratory data, and imaging findings should be considered together for a final diagnosis. US is the initial imaging modality, and features including papillary projections, calcification, fluid in the cul-de-sac, tumors ≥ 10 cm in largest diameter, lesions with irregular walls, and thickened irregular septae are red-flags for malignant ovarian neoplasms. CT is not only the study of choice for staging, but also is helpful to visualize the mass better in larger patients. Ascites, hepatic metastases, lymphadenopathy, and omental, mesenteric or peritoneal implants suggesting intraabdominal spread can also be better visualized. MR imaging is helpful for evaluation of pelvic sidewall and adjacent organs for invasion.

Uterine and vaginal tumors are rare in children. The most common tumors arising from the uterus and vagina are rhabdomyosarcomas. Endodermal sinus tumor and clear cell adenocarcinoma of the vagina are other types of tumors in that particular location.

Primary testicular tumors (germ cell tumors, sex cord-stromal tumors, and mixed tumors) represent 1%- 1.5% of all childhood malignancies, with a peak incidence at the age of 2 years. They can be located either intratesticular or extratesticular, and sensitivity of both sonography and MR imaging is nearly 100% in differentiation of lesion location. Testicular masses usually have a nonspecific appearance of a solid mass on all cross-sectional imaging modalities. Intratesticular location, invasion of tunica albuginea causing an irregular appearance, reactive hydroceles, and hypervascularity are clues for malignant testicular neoplasms. US is helpful to detect the presence of reactive hydrocele (associated with testicular neoplasms in 15-25% of cases), which may also be a finding secondary to epididymitis, orchitis, testicular torsion, torsion of the appendix testis, and trauma. Although being a nonspecific finding seen in both malignancy and inflammation, color Doppler sonography can determine the vascularity of the mass, and help to differentiate testicular torsion. Metastatic workup of a child with a testicular neoplasm should include CT of the chest, abdomen, and pelvis to screen for lung and lymph node involvement, and should be performed before surgery. US should be the screening tool for the contralateral testicle before and after orchiectomy. Periodic screening with US is recommended for patients with undescended or delayed testicular descent and testicular microlithiasis, which has a controversial association with testicular tumors.

Secondary testicular tumors (leukemia and lymphoma) represent ≤ 10% of all testicular tumors. US should be the imaging modality in a child with leukemia presenting with painless, usually bilateral, testicular enlargement. Bilateral, or less often unilateral, homogeneous, hypoechoic testicular enlargement with disorganized hypervascular flow is the characteristics of the leukemic infiltration. MR imaging (leukemia, and especially lymphoma) reveals a distinctive decrease in T2 signal intensity, which differs from most lesions.

Extratesticular neoplasms arising from epididymis (adenomatoid tumors, lipoma, rhabdomyosarcoma, papillary cystadenomas), spermatic cord (lipomas), and/or supporting tissue are usually rare and benign. Paratesticular rhabdomyosarcoma is the malignant tumor and nearly 40% of these patients have distant metastasis.

Malignant lesions of the bladder are rhabdomyosarcomas, leiomyosarcomas, and transitional cell carcinomas. Benign lesions of the bladder are fibromas, hemangiomas, hematomas, leiomyomas, and endometriomas.

Sacrococcygeal teratomas are complex lesions and may be associated with sacral and anorectal abnormalities, which is referred to as the Currarino triad (anorectal anomalies, a sacral bony defect, and a presacral mass of varios origin).

55 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY WORKSHOPS

Workshop 1: Oncologic Imaging of the female genitical tract Moderators: John Spencer, Celine Alt

WS1a Rare Tumours of the Uterus Dr Nishat Bharwani

Aims: 1.To describe imaging features of less common neoplastic lesions arising in the uterine body and cervix. 2.To illustrate some MR imaging features seen in these lesions which are suggestive of the unusual underlying diagnosis pre-operatively.

WS1b Rare tumors of the ovary I.Thomassin-Naggara

Learning objectives : 1-To review main histopathological type of rare ovarian tumors 2-To learn a MRI practical approach to make a diagnosis of ovarian tumor 3-To discuss main clinical and imaging findings that allows to recognize rare tumors of the ovary

Content : Five clinical cases with mulitple choice questions for an interactive session

Key points : - A purely solid ovarian tumor in low diffusion weighted signal is benign - Calcifications may help to characterize purely latero uterin masses - Morphologic patterns of ovarian metastasis depend of the primitive cancer - Decidualized endometrioma may mimic borderline cystadenoma but be recognized due to high T2 signal of pseudopapillary projections

WS1c Tumors of the vagina a nd vulva: the role of imaging in treatment planning and follow-up Rosemarie Forstner

Vulvar and vaginal cancer are uncommon gynecologic malignancies comprising only 3, respectively 5 % of malignancies of the female genital tract. Histologically squamous cell cancer constitutes the vast majority of tumors, followed by melanoma in vulvar and adenocancer, sarcoma and melanoma in vaginal cancer. Although vaginal cancer is rare, vaginal metastases are more common and have to be excluded.

Association with HPV- infection has been recognized as important risk factor and is found particularly in younger females.

Although the diagnosis of these cancers is based on clinical examination and biopsy, cross-sectional imaging assists in complementary tumor staging. It allows visualization of the exact extent of disease and assists in lymph node assessment.

Standard treatment of vulva cancer is surgery, with excellent 5 year survival rates for early stages. Imaging is used for treatment planning purposes and is most useful for selection of candidates with operable from those with non-operable disease. In advanced stages or in risk of high morbidity due to surgery newer treatment strategies provide individualized management. However, this is based on interdisciplinary consensus.

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Routine use of imaging is not recommended for postreatment surveillance. MRI and/or PET/CT are only recommended if recurrence is suspected. In this setting imaging assists in optimized treatment planning, mostly for exenteration.

Imaging is also performed to assess treatment related complications, e.g fistulation. The MRI protocol includes coverage of the pelvis and retroperitoneum for lymph node imaging and high resolution T2WI in 2 planes for local tumor assessment. T2FS allows superior tumor delineation from crucial surrounding structures, e.g the urethra and the anal canal compared to T2WI alone. Multiparametric imaging, including DWI and dynamic contrast imaging further improve the diagnostic performance.

WS1d Patterns of metastatic disease spread in the female pelvis Atif Zaheer, MD

Pelvic metastatic disease may be lymphatic, osseous or visceral. Different malignancies have different patterns of tumor spread and knowledge of the spread of disease has important management and prognostic implications. It is important to identify the anatomic location of the pelvic nodal groups to identify the usual pathway of lymphatic drainage of the involved organ. Identification of the regional nodes for each organ helps in the classification according to the TNM system and spread the lymph nodes outside of the regional nodes is considered M-stage, resulting in upstaging of the disease to overall stage IV cancer and affecting the treatment options as well as the overall prognosis. Similarly identification of bone metastasis is important as the spread of disease may be hematogenous or direct via invasion. Direct invasion to the adjacent structures is also common and rarely extra-pelvic tumors may also metastasize to the pelvic organs. The presentation reviews the patterns of regional nodal spread and N-stage classification are presented for carcinomas of the ovary, cervix, endometrium and the vagina. Schematic diagrams and cases examples of pelvic tumors are also presented.

WS1e PET CT in gynecological malignancies - evidence, findings and pitfalls Raghu Vikram MD University of Texas M D Anderson Cancer Center

18F- Fluorodeoxyglucose Positron Emission Tomography Computed Tomography (FDG PET/CT or PET/CT) is now being increasingly used in routine management of gynecological malignancies and have been very useful in management of patients with cervical, ovarian and endometrial carcinoma. In several instances, PET/CT has a superior sensitivity and specificity to conventional imaging as a result of the combination of anatomic and functional information these hybrid studies yield.

PET/CT is useful in management of both adenocarcinoma and squamous cell carcinomas of the cervix. It can provide prognostic information based on the standard uptake value maximum (SUV max) of the primary tumor at diagnosis, detect distant metastases which can be challenging by use of conventional staging methods, detect pelvic and extra-pelvic metastatic nodes. It provides useful information in radiation planning, follow up of patients post chemo-radiation and response assessment.

Although not very useful in characterization of ovarian masses, PET/CT is extremely useful when used selectively in patients with ovarian cancer, particularly in the setting of recurrent ovarian cancer. Patients with elevated CA-125 and negative CT or MRI and symptomatic patients benefit the most from a PET/CT. In addition, patients can be selected for site-specific treatment planning such as surgery and radiation therapy.

In grade III endometrial cancer and papillary serous tumors, PET/CT is useful in diagnosing nodes above the iliac vessels and detecting distant metastases not included in routine staging surgery, thereby altering treatment.

PET/CT can help detect the presence of lymph node metastases, the most important prognostic factor, in patients with vulvar carcinoma and other rare malignancies of the female genital tract. However, there are several technological and physiologic factors that introduce limitations, artifacts and pitfalls. Poor spatial resolution limiting characterization of sub centimeter lesions will likely be improved due to technological advances in detectors. Recognition of misregistration between the CT and PET

57 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY components can eliminate avoidable errors in interpretation. Dependence of SUV max on various factors such as scan time from injection, serum blood glucose, volume averaging from movement, attenuation correction, difference in scanners, etc. can lead to erroneous interpretation of results particularly when used for response assessment.

WS1f Imaging of Complications Following Treatment of Gynaecologic Cancers Nefise Çağla Tarhan, MD Professor of Radiology Baskent University Faculty of Medicine

Gynaecologic cancers are very common; they are accounted within the top ten cancer incidence rates among women. Carcinoma of cervix uteri has the highest incidence being in the third place. Early diagnosis and treatment is important in management of these patients. There are different treatment options and in most suitable cases surgery is the primary treatment of choice. In advanced disease, radiotherapy and chemotherapy with different regimens can also be used. Complications can occur after treatment of these cancers. Imaging has an important role in the early diagnosis of complications for further treatment options. Imaging is also important to differentiate the changes secondary to therapy and the recurrent disease. Especially with improved computed tomography (CT) with multidetector imaging techniques and magnetic resonance imaging (MRI) techniques, early diagnosis of these complications and early management is facilitated. Radical hysterectomy is performed in most patients with primary gynaecologic cancers with extensive parametrial resection and in most centers pelvic and paraaortic lymph node resection is also done. Abdominal debulking surgery is preferred in ovarian carcinoma with added omentectomy and also peritoneal implant resection in both primary and recurrent disease. These complicated surgical techniques lead to higher postsurgical complication rates. Most commonly seen postsurgical complications are haemorrhage, bowel, urinary bladder or ureter injuries, lymphocele formation in early postoperative period. Infections, fluid collections, abscess formation, fistulas (vesicovaginal, rectovaginal, enterocutaneous, enteroenteral etc), bowel obstructions and perforations are common after the first month postoperatively.

Radiotherapy is an important in cervical and endometrial carcinoma. It is indicated in patients starting from stage IB grade 3 (new FIGO staging criteria) in endometrial carcinoma. In cervical carcinoma, radiotherapy is the treatment of choice together with chemotherapy in stage IIB and higher. In postoperative period, it is indicated in patients with lymph node metastasis, in tumours with positive surgical margin and with parametrial invasion, recommended if the mass is bigger than 4 cm, have lymphovascular bed invasion, deep stromal invasion and in tumours with histology of adenocarcinoma. Bowel perforations and fistula formation are also common after pelvic radiation therapy. Intestinal perforation is also increased in incidence after the common use of bevacizumab; a humanized monoclonal antibody that inhibits vascular endothelial growth factor A, in patients with recurrent ovarian carcinoma. Other complications that may be seen after radiotherapy are radiation cystitis or proctitis, ureter strictures and insufficiency fractures of the sacrum and avascular necrosis of femoral head.

Computed tomography can be used in detection of haemorrhage and fluid collections such as lymphocele. Precontrast images can be used to detect high density (50-70 HU) hematoma within the pelvis at early postoperative period. In time it becomes low-density fluid collection with wall formation around it and resorbs eventually. If a suspicion of active bleeding is present, after contrast administration contrast extravasation confirms the diagnosis. CT is also useful in demonstrating infectious fluid collections and abscess formation. Thick-walled collections with higher density and air within the fluid are diagnostic for abscess formation. Retained surgical sponges (a rare complication of surgery) may cause reactional wall formation around it giving an abscess like appearance but marker within the sponge on plain film or CT is diagnostic.

Lymphoceles are fluid collections secondary to leakage of lymphatic fluid after lymphadenectomy. They are most commonly seen after ovarian carcinoma surgery around the iliac vascular structures. They are usually thin-walled, asymptomatic and regress in time. If it reaches bigger sizes or if symptomatic, US-guided drainage with sclerotherapy can be done.

Bowel perforations within the first week after surgery are more difficult to diagnose because there is usually free air within the peritoneal cavity secondary to surgery. Excess free air or persistent air after the first postsurgical week with symptoms of peritonitis is diagnostic for bowel perforation. In cases of suspicion (like after recent surgery or presence of drainage catheters), CT with oral contrast will show if there’s any contrast

www.esur2013.org 58 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY extravasation from the bowel. It is also useful to show the site of perforation. It demonstrates if contrast extravasation is free within the peritoneal cavity or if it is a closed perforation. Fistulas are common after surgery combined with radiotherapy. Most common fistulas are vesicovaginal and rectovaginal. MRI is the imaging of choice in these fistulas with its higher soft-tissue contrast and multiplanar imaging capability. On MRI, STIR and post-contrast fat-saturated T1-weighted images are most valuable. CT can be used to depict all enteral fistulas. After administration of oral contrast, detection of contrast within the fistula tract is diagnostic. Ureteral and bladder communicated fistulas can also be demonstrated with late venous phase CT images if enough contrast reaches the ureters and bladder. If there is suspicion of these types of fistulas, late phase imaging can be performed 10-20 minutes after IV-contrast administration. Urinary tract injuries are also higher after radical hysterectomy. Ureter obstructions and ureter lacerations are common injuries. Obstruction may be suspected on US if there’s hydronephrosis early postoperatively. It can be demonstrated on CT. Ureteral laceration with extravasation of contrast is best shown on late-phase CT images and CT urography. Ureteral strictures may develop as a late sequela of radiotherapy. They are diagnosed on CT or MRI images with dilatation and obstruction of ureter.

Bowel obstruction is usually seen in patients who received multiple therapies after surgery and after second look operations. Small bowel obstructions are more common. CT imaging without oral contrast is preferred in the diagnosis of obstruction. If there is partial obstruction suspected, oral contrast can be used.

Radiation cystitis and proctitis usually show diffuse thickening of the bladder or rectal wall. It is best differentiated with contrast-enhanced MRI. Diffusion-weighted images help differentiating them from tumoral infiltration.

Sacral insufficiency fractures and avascular necrosis of femoral head are best diagnosed on pelvic MRI. The radiated bone also shows diffuse fat replacement, which is important to differentiate the patients who received radiotherapy if the patients’ history cannot be reached.

Complications can be seen after different treatment options of gynaecologic cancers. It is important to be aware of the possible complications and early diagnosis is crucial. Imaging with new techniques help early diagnosis and management.

59 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 2: Imaging of the patient with hematuria Moderators: Wael Shabana, Mehmet Ertürk

WS2a IVP and US: Role in future? Julian Keanie

WS2b Non-contrast CT and CT urography Dr.Ercan Kocakoç Department of Radiology, Bezmialem Vakif University, Istanbul, TR

Hematuria is a common clinical problem which can be either microscopic or macroscopic. Causes of hematuria may change from urinary tract infection or stone disease to carcinoma. Imaging plays a crucial role to demonstrate cause of hematuria and to guide management of patients. Non-contrast CT is currently the first preferred imaging modality for evaluation of stone diseases at many institutions. Its sensitivity and specificity is higher than ultrasound and other conventional imaging modalities such as excretory urography for detection stone disease and stone related cause of hematuria. Using multidetector CT (MDCT), thin- collimation (3- to 5-mm), non-contrast scans are obtained through the abdomen from the superior aspect of the kidneys (or from the dome of the liver) to the inferior aspect of the bladder base or pubic symphysis. This technique is simple and does not require any patient preparation or administration of oral or IV contrast. If CT does not display evidence of stones, subsequent imaging with IV contrast is needed. Regardless of their calcium content, almost all urinary tract calculi are radio-opaque on non-contrast CT. Reconstructed images, such as multiplanar reconstruction (MPR) or curved planar reconstruction (CPR), are useful in demonstrating the exact location of stones and their relationship to the ureter. Non-contrast CT also is helpful in detecting non-obstructing calculi in patients who have hematuria (Kocakoc E, et al., Radiol Clin North Am 2005). Until recently, intravenous urography (IVU) or excretory urography was used as traditional imaging technique for the radiologic evaluation of the kidneys, pelvicaliceal systems, ureters, and bladder. IVU has lower sensitivity in detecting small renal masses.

One of the advantages of IVU over CT is its ability to detect intraluminal filling defects and mucosal abnormalities in the renal collecting systems and ureters. Excretory-phase collecting system opacification obtained during CT urography (CTU) was found to be comparable to collecting system opacification obtained during IVU. With advances in CT technology, the technique of CT urography is used to evaluate the entire urinary system. MDCT enables faster data acquisition and higher resolution images than single-detector helical CT with very thin (approximately 0.5 mm) slices. The entire urinary system (ie, kidneys, ureters, and bladder) are visualized in one breath-hold on MDCT. Its initial thin data acquisition enables better quality reconstructed and reformatted coronal images similar to those of IVU.

CT Urography is defined as a diagnostic examination optimized for imaging the kidneys, ureters and bladder by CTU working group (van der Molen AJ, et al. Eur Radiol 2008). The examination involves; the use of MDCT with thin-slice imaging, IV administration of a contrast medium, and imaging in the excretory phase. Early or late excretory phases are mandatory for any CTU examination. Similar to isotropic or completely isotropic high quality images can be obtained with MDCT. The only advantage of IVU over CTU; IVU can show mucosal abnormalities and filling defects in renal collecting system and ureters. Nowadays, CT Urography is used instead of IVU. The level of opacification of collecting system and ureters obtained with excretory phase CT is comparable with IVU. CT Urography not only shows the lumen of the urinary tract, but also shows the urinary tract wall structure and surrounding tissues. CT Urography does not require a specific preparation. Creatinine level (< 1.4 mg/dL) should be known. If there is a contraindication to the use of contrast material, examination should not be performed. Positive oral contrast should not be given; it may obscure 3D images. Oral hydration with water is beneficial (20 min-1 hour before the examination; up to 1 L), which increases the diuresis, and provides better visualization of ureteral segments. If oral intake of water not tolerated, up to 500 ml IV drip infusion of saline can be given during the procedure. Using IV injection of low-dose diuretics (5 - 10 mg of furosemide) before IV contrast injection allows less dense, homogeneous opacification of the collecting system.

In this presentation, indications of non-contrast CT and CTU, CT urography techniques, the advantages and disadvantages of these techniques, utility of CT urography in routine practice and examples of cases in clinical practice will be discussed.

www.esur2013.org 60 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WS2c MR Urography MR Urography Tarek El-Diasty, Mansoura-Egypt

MR urography (MRU) represents assessment of the renal collecting systems, ureters, and bladder utilizing either T2W (static, static-fluid) or T1W (excretory) images. The concept of MRU is to obtain typical urographic view without resorting to radiation exposure and iodinated CM. In patients with hematuria, a comprehensive MRU protocol can be used. This protocol includes urographic sequences (urinary tract anatomy and urothelium), standard sequences (vascular & soft tissue anatomy and evaluation of masses and inflammatory processes), and adjuncts (hydration, diuretics and IV contrast).

Learning objectives: - To recognize the role of MR urography as an alternative, complementary, or primary imaging study for patients with hematuria. - To understand the clinical value of different MR techniques used to image patients with hematuria. - To describe the imaging features of different causes of hematuria on MR urography.

WS2d

Which modality is appropriate for hematuria? C Roy Department of Radiology B New Civil Hospital Universitary Hospital of Strasbourg France

Technologic advances in both computed tomography (MDCT) and magnetic resonance (MR) imaging have resulted in the ability to image the urinary tract in ways that surpass the ancient X-rays. Although both tests can be used to evaluate the urinary tract, several issues remain and reach a consensus on the optimal protocols and appropriate utilization in an era of cost.

US is widely used as the first imaging study to evaluate kidney with a rather good sensitivity but inferior to that of others modalities. The emerging Contrast Enhanced US (CEUS) is promoted as an interesting tool to better classified complex cystic lesions within the Bosniak classification and it provides a dynamic evaluation of the contrast enhancement.

The two cross sectional modalities have the ability to display the entire urinary tract, including renal parenchyma, pelvicaliceal systems, ureters and the bladder using a single imaging test. However, the workhorse technique used in routine practice to evaluate hematuria is the MDCT.

Hematuria is a common urologic problem. The prevalence of asymptomatic microscopic hematuria varies 0.6%–21%. Even if the cause for microscopic hematuria it is not always due to the presence of serious disease, CT urography is recommended in those patients as the initial imaging test. In addition, MDCT or MR is efficient in detecting unsuspected extraurinary disease.

Hematuria and positive points for MDCT :

1. MDCTU accurately detects urinary tract calculi on the initial unenhanced CT. It can detect relatively subtle abnormalities such as papillary necrosis and renal tubular ectasia. It can confirm the presence of obstructing or non-obstructing calculi with contrast medium injection ; even if obstruction can be diagnose on unhanced CT when there is an hydronephrosis and/or a modification of the perirenal fat.

2. Acute pyelonephritis is well characterized by MDCTU with solitary or multifocal hypodense areas with obliteration of normal corticomedullary differentiation, best demonstrated on CT images obtained in the nephrographic phase. Focal low attenuation regions suggest renal abscess. The finding of gas within a parenchymal fluid collection or the renal collecting system is consistent with more severe infection

61 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

3. Caliceal diverticulum may be seen on a non-contrast study, as a loculated pocket of “milk of calcium” in a peripheral location. On delayed phase images, this area fills with contrast and a peripheral contrast-filled “pouch” can be identified. Similarly, differentiation of hydronephrosis from parapelvic cysts can also be easily established in the excretory phase.

4. CT can detect up to 47% of renal parenchyma masses measuring 5mm and 75% of masses measuring 10-15 mm in diameter. Transitional cell carcinoma is the commonest malignant neoplasm of the urothelium. In the early stages, these neoplasms are seen as subtle filling defects or focal mural thickening. It is now believed that adequate distension and opacification of the ureter and pelvicaliceal system are fundamental factors in the thorough evaluation of the urothelium. Coronal 2Dand 3D reconstructions of the ureters provide anatomic views of the urinary tract similar to those seen at excretory urography with longitudinal extension of a lesion or the presence of multicentric tumors. The Bosniak classification system is used to graduate cystic masses: It is helpful to differentiate category I, III and IV cysts. It is critical to differentiate between complicated cysts of categories II and III. The pseudoenhancement artifact of small intraparenchymal cysts can lead to an upgraded Bosniak cyst classification with major implications for prognosis and clinical management.

Hematuria and corresponding points for MR

1. The main disadvantage of MR urography is its inability to reliably detect urinary tract calcifications (depending on the size) and air. MR is relatively insensitive for the detection of calculi and this diagnosis of ureteral calculi often relies on detecting secondary signs of obstruction such as ureteral dilatation and perinephric fluid. The sensitivity of MR urography for ureteral calculi is technique dependent, with higher sensitivities reported for excretory MR urography than for static-fluid T2- weighted techniques. MR urography is more sensitive for diagnosing the cause of urinary tract obstruction or hydronephrosis due to causes other than urolithiasis (superior to CT in that it provides better tissue contrast resolution).

2. The value of MR imaging for early diagnosis of pyelonephritis is still under debate. Heterogeneous enhancement of renal tissue can also be seen with MR imaging. Probably DWI is helpful because of its high senstivity in the detection of parenchymal oedema. Magnetic resonance imaging findings of abscesses are similar to those of CT.

3. MRU has advantage over MDCTU to image the pelvicaliceal systems without intravenous iodinated contrast agents using heavily T2 weighted ultrafast sequences.

4. For neoplasms, it is likely that with continued technologic improvements in terms of spatial resolution, imaging times decrease, the use of MR will increase. Nowadays, MR is commonly used to better characterize renal masses (greater sensitivity for contrast enhancement, and more information about tissue properties) especially with the development of diffusion weighted imaging. MR is very accurate to analyse cystic masses. Although urothelial neoplasms can be detected with MR urography, its sensitivity remains to be determined

Finally, MR has the potential to be used for more indications in the near future.

Patients with renal insufficiency remain a problem for both MDCT (contrast-induced nephropathy) and MR urography (nephrogenic systemic fibrosis)

CT MR -ionizing radiation, low-dose procedure -uses magnetic resonance, no ionizing radiation -excellent spatial resolution -excellent contrast resolution -scanning time (typically <10 s) -scanning time (typically 40 min) -excellent at showing calcification -poor at showing calcification (signal void) -poor at showing edema or pathological excellent at showing edema and pathological changes in specific tissue types changes in specific tissue types -usually requires contrast -can be tailored without contrast if c i -iodine induced nephropathy -nephrogenic systemic fibrosis (rare) -available in emergencyunit -Not routinely available in emergency -few artifacts -prone to artifacts (especially motion artifact)

www.esur2013.org 62 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 3: Imaging of the patient with hematuria Moderators: Devrim Akıncı, Sami Moussa

WS3a Renal thermal ablation N. Grenier, F. Cornelis Service d’Imagerie Diagnostique et Interventionnelle de l’Adulte Groupe Hospitalier Pellegrin Place Amelie Raba-Leon - 33076 BORDEAUX Cedex – France

Over the last few decades, the increasing use of imaging in many diseases has profoundly altered the natural history of kidney cancer. Nearly 50% of kidney cancers diagnosed are currently discovered by chance [1]. This has meant earlier detection of often small, renal tumours, and in 70 to 80% of cases, while they are still in a non-metastatic stage [2,3].

These changes in presentation and prognosis have considerably modified the management of renal cell carcinomas (RCC), particularly over the last ten years, with the development of nephron-sparing techniques replacing open surgery. After an initial development using laparoscopy, the percutaneous approach is now predominating with a shorter period of hospitalisation [4] and reduced overall cost [5]. This review aims to provide the benefits, limitations, complications and performance reported.

Guidance methods The percutaneous approach is possible using CT, MRI or ultrasound. CT guidance is currently better for localizing the tumor and controlling the procedure. The limits and relationships of the tumour to be treated can be precisely determined, but nevertheless it can be adversely affected by the patient’s breathing movements, which justifies positioning the applicators during apnea.

As an alternative, or associated with CT, ultrasound guidance has proved to be feasible and to provide good procedural safety [6,7] and can be an effective aid for fast and accurate positioning of the applicators. Finally, MRI guidance provides real-time monitoring of the ablation site [8] but it is limited by restricted accessibility and MRI compatible equipment.

Performing biopsies When thermal ablation treatment is decided, pre-treatment biopsy is justified, firstly because there will be no postoperative surgical specimen, and because nearly 20% of T1 tumours are estimated to be benign (particularly when less than 3 cm [9].

In certain special cases (e.g. von Hippel Lindau disease, a recent history of RCC), a biopsy is not essential. Similarly, for cystic tumours, the risk of malignancy can currently be evaluated using Bosniak’s classification [2].

A biopsy performed during the ablation session has the advantage of saving time and morbidity. However, due to a significant proportion of negative or benign results, biopsy is now proposed during a procedure prior to thermal ablation [10].

Clinical results Thermal ablation using radiofrequency Since Zlotta et al. [11], many studies have reported the efficacy of radiofrequency ablation on RCC, even though long-term studies are not yet available. Primary efficacy is 67 to 100% [12—14,23]. Results depend on follow-up duration and tumor size. The secondary efficacy of RF is more informative and representative of the contribution of the technique to oncological control, with values between 90 and 100% [12,15,16,17,18]. In a small series, comparing 37 patients treated by partial nephrectomy with 40 patients treated by percutaneous or laparoscopic radiofrequency, Stern found no significant difference in recurrence-free survival at 3 years for T1a tumors, with respective levels of 95.8% and 93.4% [19].

Size and sinus extension of the tumor can increase the risk of technical failure [17]. In a series of 104 patients and 125 tumors, Zagoria et al treated all cancers measuring less than 3.7cm completely. The

63 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY survival rate without recurrence fell to only 47% for tumors over 3.7 cm in size. For tumors larger than 3.6cm, the risk of recurrence increased by a factor 2.19 for each additional centimeter. They didn’t find significant difference whether the site of the lesion was exophytic, parenchymal, central or mixed [14]. Gervais, in a series of 85 patients and 100 tumors, identified tumor factors of primary efficacy. Only the non-central site of lesions is described as an independent factor of secondary efficacy. A cut-off at 4 cm produced treatment that was 90% complete. A cut-off at 5.8 cm would mean 99% of patients could be treated completely, but with a short-term success rate of 63% [12]. Local recurrence free survival at 5 years is in the order of 89 to 92% [12,13]. In a long-term follow-up of a mean of 61.6 months in 31 patients, Levinson describes only three in situ recurrences, all occurring before 31 months, and no metastatic development [16].

Cryotherapy A major advantage of cryoablation is the ability to monitor the ablation zone in real time [20,21] by visualising the physical changes caused by freezing. This is particularly useful when the lesion to be treated is close to sensitive organs or structures. Another advantage is that there is no denaturing of protein, as in hyperthermic treatment, in the architecture of supporting tissues, particularly urothelial tissue. There is no evidence of any superiority of cryo over RF in term of free recurrence survival.

Microwave thermal ablation Microwave ablation is a technique is not limited by desiccation, carbonisation or thermal convection [23]. As a consequence, the temperature obtained is high, and can result in a larger ablation zone in shorter time. Liang et al. [22] recently reported the results of a feasibility study in which 12 patients were treated with no remnant or recurrence at a mean follow-up of 11 months. Carrafiello et al. [24] also performed 12 successful procedures, with a mean follow-up of 6 months. It is however necessary to analyze complications, tolerance and efficacy in the medium term.

Complications The low morbidity of percutaneous thermal ablation is a major advantage for patients who are poor candidates for surgery [25]. The complication rate for thermal ablations reported in the literature is variable, 4%-37%, because of absence of standardization in grading side effects [26]. Perirenal haematoma is the most common complication, (0-30%) [12,27,28], particularly using cryotherapy. Most are minor, the risk of major bleeding being between 0%-2% [12,14]. Pain and neuromuscular weakness is usually temporary [14] and uncommon (4.5%) [13], due to lesions of the lumbar plexus, subcostal or genitofemoral nerves [9,30,31]. Incidence of pneumothorax is 1 to 2% [14,29] most being minor [32]. Thermal lesions of the digestive tract is a major complication specific to hyperthermia. It is rare, (0%-1%) [12, 27]. The colon, particularly exposed with upper pole and anterior tumours [33], seems to be most at risk. Prevention is essential by using hydrodissection (exclusively glucose or sterile water) and/or CO2 dissection [34]. The upper urinary tract is particularly exposed during treatment of central tumours by hyperthermia, in contrast to cryotherapy. Complications are less than 4% in the literature [12,14,29,33]. Infection is not negligible, in the order of 0%-2% [7,25], diabetes increasing risk [30].

Conclusion Apart from the need for large-scale validation of newly developing techniques such as microwaves and focused ultrasound, the long-term results of radiofrequency and cryotherapy ablations need to be confirmed. Nevertheless, given the low morbidity of these techniques and the excellent oncological efficacy reported in the management of kidney tumours of less than 4 cm, enlarging the indications to a wider population can be envisaged.

References [1] Jayson M, Sanders H. Increased incidence of serendipitously discovered renal cell carcinoma. Urology 998;51(9495698):203—5. [2] Bosniak MA, Birnbaum BA, Krinsky GA, Waisman J. Small renal parenchymal neoplasms: further observations on growth. Radiology 1995;197(3):589—97. [3] Homma Y, Kawabe K, Kitamura T, Nishimura Y, Shinohara M, Kondo Y, et al. Increased incidental detection and reduced mortality in renal cancer — recent retrospective analysis at eight institutions. Int J Urol 1995;2(7553292):77—80.

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[4] Hui GC, Tuncali K, Tatli S, Morrison PR, Silverman SG. Comparison of percutaneous and surgical approaches to renal tumor ablation: metaanalysis of effectiveness and complication rates. J Vasc Interv Radiol 2008;19(18725094):1311—20. [5] Mues AC, Landman J. Image-guided percutaneous ablation of renal tumors: outcomes, technique, and application in urologic practice. Curr Urol Rep 2010;11(20425631):8—14. [6] del Cura JL, Zabala R, Iriarte JI, Unda M. Treatment of renal tumors by percutaneous ultrasound-guided radiofrequency ablation using a multitined electrode: effectiveness and complications. Eur Urol 2010;57(19926208):459—65. [7] Veltri A, Garetto I, Pagano E, Tosetti I, Sacchetto P, Fava C. Percutaneous RF thermal ablation of renal tumors: is US guidance really less favorable than other imaging guidance techniques? Cardiovas Interv Radiol 2009;32(18709413):76—85. [8] Boss A, Clasen S, Kuczyk M, Schick F, Pereira PL. Image-guided radiofrequency ablation of renal cell carcinoma. Eur Radiol 2007;17(17021704):725—33. [9] Pahernik S, Ziegler S, Roos F, Melchior SW, Thuroff JW. Small renal tumors: correlation of clinical and pathological features with tumor size. J Urol 2007;178(17561161):414—7. [10] Goldberg SN, Grassi CJ, Cardella JF, Charboneau JW, Dodd 3rd GD, Dupuy DE, et al. Image-guided tumor ablation: standardization of terminology and reporting criteria. J Vasc Interv Radiol 2005;16(6):765—78. [11] Zlotta AR, Wildschutz T, Raviv G, Peny MO, van Gansbeke D, Noel JC, et al. Radiofrequency interstitial tumor ablation (RITA) is a possible new modality for treatment of renal cancer: ex vivo and in vivo experience. J Endourol 1997;11(9376843):251—8. [12] Gervais DA, Arellano RS, McGovern FJ, McDougal WS, Mueller PR. Radiofrequency ablation of renal cell carcinoma: part 2. Lessons learned with ablation of 100 tumors. AJR 2005;185(15972401):72—80. [13] Mylona S, Kokkinaki A, Pomoni M, Galani P, Ntai S, Thanos L. Percutaneous radiofrequency ablation of renal cell carcinomas in patients with solitary kidney: 6 years experience. Eur J Radiol 2009;69(18313248):351—6. [14] Zagoria RJ, Traver MA, Werle DM, Perini M, Hayasaka S, Clark PE. Oncologic efficacy of CT-guided percutaneous radiofrequency ablation of renal cell carcinomas. AJR 2007;189(17646471):429—36. [15] Tracy CR, Raman JD, Donnally C, Trimmer CK, Cadeddu JA. Durable oncologic outcomes after radiofrequency ablation: experience from treating 243 small renal masses over 7.5 years. Cancer 2010;116(20564644):3135—42. [16] Levinson AW, Su L-M, Agarwal D, Sroka M, Jarrett TW, Kavoussi LR, et al. Long-term oncological and overall outcomes of percutaneous radio frequency ablation in high risk surgical patients with a solitary small renal mass. J Urol 2008;180(18550123):499—504. [17] Veltri A, Grosso M, Castagneri F, Garetto I, Sacchetto P, Tosetti I, et al. Radiofrequency thermal ablation of small tumors in transplanted kidneys: an evolving nephron-sparing option. J Vasc Interv Radiol 2009;20(5):674—9. [18] Salagierski M, Salagierski M, Salagierska-Barwinska A, Sosnowski M. Percutaneous ultrasound-guided radiofrequency ablation for kidney tumors in patients with surgical risk. Int J Urol 2006;13(17083386):1375—9. [19] Stern JM, Svatek R, Park S, Hermann M, Lotan Y, Sagalowsky AI, et al. Intermediate comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumours. BJU Int 2007;100(17617136):287—90. [20] Aron M, Hegarty NJ, Remer E, O’Malley C, Goldfarb D, Kaouk JH. Percutaneous radiofrequency ablation of tumor in transplanted kidney. Urology 2007;69(4):778e5—7. [21] Onik GM, Reyes G, Cohen JK, Porterfield B. Ultrasound characteristics of renal cryosurgery. Urology 1993;42(8367932):212—5. [22] Liang P, Wang Y. Microwave ablation of hepatocellular carcinoma. Oncology 2007;72 Suppl. 1(18087193):124—31. [23] Wright AS, Sampson LA, Warner TF, Mahvi DM, Lee FT. Radiofrequency versus microwave ablation in a hepatic porcine model. Radiology 2005;236(15987969):132—9.

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[24] Carrafiello G, Mangini M, Fontana F, Recaldini C, Piacentino F, Pellegrino C, et al. Single-antenna microwave ablation under contrast-enhanced ultrasound guidance for treatment of small renal cell carcinoma: preliminary experience. Cardiovasc Interv Radiol 2010;33(2):367—74. [25] Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 2007;178(17574056):41—6. [26] Pasticier G, Timsit MO, Badet L, De La Torre Abril L, Halila M, Fassi Fehri H, et al. Nephron-sparing surgery for renal cell carcinoma: detailed analysis of complications over a 15-year period. Eur Urol 2006;49(16443321):485—90. [27] Breen DJ, Railton NJ. Minimally invasive treatment of small renal tumors: trends in renal cancer diagnosis and management. Cardiovasc Interv Radiol 2010;33(20544228):896—908. [28] Varkarakis IM, Allaf ME, Inagaki T, Bhayani SB, Chan DY, Su L-M, et al. Percutaneous radio frequency ablation of renal masses: results at a 2-year mean follow-up. J Urol 2005;174(16006864):456—60. [29] Breen DJ, Rutherford EE, Stedman B, Roy-Choudhury SH, Cast JEI, Hayes MC, et al. Management of renal tumors by imageguided radiofrequency ablation: experience in 105 tumors. Cardiovasc Interv Radiol 2007;30(17573550):936—42. [30] Rhim H, Dodd GD, Chintapalli KN, Wood BJ, Dupuy DE, Hvizda JL, et al. Radiofrequency thermal ablation of abdominal tumors: lessons learned from complications. Radiographics 2004;24(14730035):41—52. 2009;19(19350243):2180—90. [31] Cornelis F, Buy X, Andre M, Oyen R, Bouffard-Vercelli J, Blandino A, et al. De novo renal tumors arising in kidney transplants: midterm outcome after percutaneous thermal ablation. Radiology 2011;260(3):900—7. [32] Park BK, Kim CK. Prognostic factors influencing the development of an iatrogenic pneumothorax for computed tomography-guided radiofrequency ablation of upper renal tumor. Acta Radiol 2008;49(19031183):1200—6. [33] Weizer AZ, Raj GV, O’Connell M, Robertson CN, Nelson RC, Polascik TJ. Complications after percutaneous radiofrequency ablation of renal tumors. Urology 2005;66(16360436):1176—80. [34] Arellano RS, Garcia RG, Gervais DA, Mueller PR. Percutaneous CT-guided radiofrequency ablation of renal cell carcinoma: efficacy of organ displacement by injection of 5% dextrose in water into the retroperitoneum. AJR 2009;193(19933665):1686—90.

WS3b Embolisation of male varicocele Dr. S. A. Moussa, MB BCh, FRCS Ed, FRCR Consultant Uro-Radiologist,Western General Hospital, Edinburgh, UK

Definition:

Varicocele is a common benign condition affecting mainly adolescents and young men. It manifest by dilatation of the pampiniform plexus of veins (draining the testes). The condition is commoner on the left side mainly due to the different anatomical course of the gonadal veins. The exact cause is not clear but is probably due to: •Absent or incompetent valves •Compression of LRV (nutcracker phenomenon)

Etiology & incidence: •Still poorly understood •Usually left sided (sub-clinical right). Bilateral presentation is less common •Impaired sperm quality and quantity in 30%-50% of men with varicocele. •Found in 55% of male population •Found in 44% of males attending fertility clinics •> 400 publications in last 5 years

www.esur2013.org 66 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Pathophysiology: •Multi-factorial •Possible pre-existing genetic disposition •Increased testicular blood flow •Increased testicular temperature •Increased venous tension •Increased oxidative stress Varicocele when symptomatic usually present as dull scrotal pain, but are often asymptomatic found incidentally during scrotal ultrasound or during investigations of subfertility.

Diagnosis: The condition is usually diagnosed clinically typically as a “bag of worms” at the neck of the scrotum. An impulse with cough is usually palpable or detected by a hand held Doppler device. The diagnosis is easily confirmed by Ultrasound with colour Doppler. Classically showing dilated veins in the spermatic cord, epidydimis or the testis. Veins typically increase is width with Valsalva and show reverse flow (reflux) on colour Doppler.

Treatments:

Indications: •Subfertility / poor semen quality •Discomfort/pain •Small testis in adolescence

Treatment options: •Surgery: •Varicelectomy •Ligation: •High ligation •Low ligation •Laparoscopic ligation •Percutaneous Embolisation •Advantages: •Day case/Outpatient procedure •Local anaesthesia •Cost (emb. £250 v surg. £570) •More suitable for recurrences and after failed surgery •Disadvantages •Requires skill/training (Interventional Radiologist) •Radiation (gonad shielding) •Reaction to contrast or L.A. The technique of varicocele embolisation will be discussed as well as a review of the results from the literature.

Conclusion: Percutaneous varicocele embolisation is a simple and cost effective treatment which should be considered as a first choice when the necessary expertise is available.

WS3c Intensification of the interaction between Urologists and Interventional Radiologists Jochen Walz

67 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 4: Functional Imaging and Tissue Characterization of the Urogenitical Tract Moderators: Harriet Thoeny, Bernd Hamm

WS4a Role of PET-CT/MR-PET Imaging in urogenital oncology Raj Mohan Paspulati

Target audience: This course is aimed at radiologists, urologists and gynecologists who wish to review the impact of MR-PET in diagnosis, staging and management of patients with urogenital malignancy

Outcome/Objectives: Attendees will be able to understand the basic concepts of MR-PET, applications and limitations of PET-CT; applications and advantages of MR-PET.

Purpose: To promote a better understanding of the role of MR-PET in staging and managing patients with urogenital malignancy.

Discussion: Current imaging methods for diagnosis and staging of Renal cell carcinoma (RCC) and urothelial malignancy (TCC) is predominantly by CT and with limited utility of MRI in selected patients. Unlike in GI tract malignancy 18 FDG PET-CT has limited role in initial staging of RCC and TCC due to variable avidity of RCC to 18 FDG tracer and its predominant renal excretion. Hence focus is being made on new tracers with negligible renal excretion. Studies have shown that FDG- PET has some role in follow up of patients with RCC following resection.

Staging of testicular cancer is by CT after the initial diagnosis of primary by Ultrasonography.Non seminomatous tumors are less avid than seminomas to 18 FDG tracer.

MR imaging is the standard of practice for local staging of Prostate carcinoma and diagnosis of distant metastases is by CT and bone scintigraphy. Due to low avidity of FDG-PET, PET-CT is not the choice of imaging for staging and emphasis is being made on use of new radiotracers such as C11-acetae and C11- choline.

Due to excellent soft tissue contrast, MR imaging is the imaging modality for local staging and treatment planning of cervical and endometrial carcinomas is the most widely used imaging method for detection of extra pelvic metastases and initial staging. 18 FDG-PET tracer has high uptake in both these malignancies and is being used in initial staging as well as follow up for local recurrence and distant metastases. Combining MR with 18 FDG-PET would over come the limitations of low soft tissue contrast of CT in these patients.

Staging and follow up of ovarian carcinoma is by mainly by CT as 18 FDG-PET has variable uptake depending upon the morphology and grade of the primary tumor.MR imaging with use of functional Diffusion weighted imaging has better sensitivity and specificity in detection of peritoneal implants. Combination of 18FDG-PET with MR has advantages of overcoming the limitations of FDG-PET and MR in their stand alone configurations.

Conclusion: MR-PET is still a fairly new technology and though preliminary studies has shown great potential for this new hybrid imaging, further studies have to be undertaken to establish its role and its cost effectiveness.

References: Drzezga A, Souvatzoglou M, Eiber M, et al. First clinical experience with integrated whole-body PET/MR: comparison to PET/CT in patients with oncologic diagnoses. Journal of nuclear medicine : official publication, Society of Nuclear Medicine 2012;53(6):845-855.

The potential clinical value of FDG-PET for recurrent renal cell carcinoma.Nakatani K, Nakamoto Y, Saga T, Higashi T, Togashi K.Eur J Radiol. 2011 Jul;79(1):29-35.

Positron emission tomography with 11C-acetate and 18F-FDG in prostate cancer patients.Fricke E, Machtens S, Hofmann M, van den Hoff J, Bergh S, Brunkhorst T, Meyer GJ, Karstens JH, Knapp WH, Boerner AR.Eur J Nucl Med Mol Imaging. 2003 Apr;30(4):607-11. Epub 2003 Feb 13.

MRI and PET scans for primary staging and detection of cervical cancer recurrence. Liyanage SH, Roberts CA, Rockall AG. Womens Health (Lond Engl). 2010 Mar;6(2):251-67; quiz 268-9

www.esur2013.org 68 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WS4b Elastography JM Correas MD PhD1+2, N Grenier MD PhD3, M Tanter PhD2 1:Paris-Descartes University & Necker University Hospital, Department of Adult Radiology, Paris, France 2:Langevin Institute Images and Waves ESPCI Paris Tech, CNRS UMR 7587 INSERM U 979, Paris, France 3:Bordeaux Segalen University & Pellerin University Hospital of Bordeaux, Department of Diagnostic and Interventional Imaging, Bordeaux, France

New developments in ultrasonic evaluation of functional imaging and tissue characterization have become available with the introduction of contrast-enhanced ultrasound (CEUS) and elastography. These two techniques can be used in order to assess renal and prostatic disorders. If CEUS provides information about tissue vascularity, elastography provides information about tissue stiffness.

Ultrasound Elastography (US-E) was developed in the 1990’s to map tissue stiffness and reproduces or replaces the palpation performed by clinicians. The principles of US-E will be reviewed, from quasi-static methods that require a static compression of the tissue to dynamic methods that uses the propagation of mechanical waves. Several dynamic methods will be discussed: transient elastography, Acoustic Radiation Force Impulsion (ARFI), shear wave imaging... However, there is an obvious link between tissue perfusion and tissue stiffness, as any decrease in perfusion will get the tissue softer. US-E can be applied to study focal renal lesions and diffuse renal disorders including chronic kidney disease (CKD). As the technique is only recently reaching the clinical practice, they are little data about characterization of focal renal masses. CKD incidence and prevalence are increasing in Western countries, due particularly to diabetes mellitus and hypertension-related nephropathies. CKD may lead to end- stage renal failure, with extensive morbidity, mortality and increasing health costs. Primary and secondary prevention requires a better knowledge of mechanisms underlying renal scarring, the development of specific therapies to slow down the progression of the disease and the development of non-invasive diagnostic tools to characterize the process. US-E is a new imaging technique under development that provides information about renal stiffness. Kidney elasticity measurements with ultrasound should be performed with a quantitative technique, such as Shear Wave techniques. However kidney stiffness is not only related to fibrosis, as it also sensitive to mechanical and functional parameters such as anisotropy, vascularization, hydronephrosis and external pressure. US-E is a new tool currently under evaluation for renal transplant complication and needs further clinical validation.

Prostate cancer is a public health issue, because it is the cancer with the highest incidence rate and the second cause of cancer death in men, the first cause being lung cancer. There were around 790,000 cases in the United States in 2012, and 241,740 new cases! Prostate cancer is difficult to detect, and the treatment efficacy remains limited despite the increase use of biological tests (PSA - prostate-specific antigen dosage), the development of new imaging modalities, and the use of invasive procedures such as biopsy. PSA screening leads to a substantial number of unnecessary biopsies in patients with no cancer or with indolent cancer that do not need immediate treatment, with an estimated over-detection rate ranging from 27% to 56%. The false negative rate of prostate biopsy varies from 17 to 21%, in patients with a negative first series of biopsies. Many urologists are now facing a dilemma when patients present with an abnormal level of PSA and negative biopsies: when should one stop and when should one continue carrying out biopsies? Finally, although PSA levels and biopsy results are correlated with the clinical stage, tumour volume and histologic tumour grade, the information provided is limited for predicting the tumour mass and its aggressiveness in each patient.

Ultrasound elastography is a novel imaging technique capable of mapping tissue stiffness of the prostate. It is known that prostatic cancer tissue is often harder than healthy tissue (information used by digital rectal examination). Two elastography techniques have been developed based on different principles: first, quasi- static (or strain) technique, and second, shear wave technique.

The tissue stiffness information provided by US elastography should improve the detection of prostate cancer and provide guidance for biopsy. Prostate elastography provides high sensitivity for detecting prostate cancer and shows high negative predictive values, ensuring that few cancers will be missed. US-E should become an additional method of imaging the prostate, complementing the conventional transrectal ultrasound and MRI. This technique requires significant training (especially for quasi-static elastography) to become familiar with acquisition process, acquisition technique, characteristics and limitations, and to achieve correct diagnoses.

69 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WS4c Renal CT-Perfusion Mike Notohamiprodjo

Renal dynamic contrast enhanced Computed-Tomography/ CT-Perfusion allows for multiphasic acquisition with a high temporal and spatial resolution. This technique facilitates multiple low-dose CT-acquisitions of an organ of interest with only low doses of contrast media, thus minimizing the risk of contrast induced nephropathy.

This lecture focuses on the acquisition protocol as well as the clinical application in renal imaging. CT- Perfusion allows for assessment of the renal vasculature as well as convenient measurement of perfusion and filtration by using kinetic models, such as the Patlak-model. This technique can be used in the pre- operative work-up of living organ donors or in the follow-up of renal transplants, e.g. for detection of acute rejection or acute tubular necrosis. Furthermore it enables assessment of renal lesions and response of advanced and metastatic RCC towards anti-angiogenic drugs, such as tyrosine-kinase-inhibitors.

Learning Points: -CT-Perfusion: Acquisition and Postprocessing -Assessment of living donors -Assessment of renal transplants -Assessment of tumors and metastases

WS4d Renal MR Perfusion Hersh Chandarana

Outline Functional renal imaging is an evolving field which has the potential to provide insight in understanding the pathophysiology of renal diseases. Techniques like dynamic contrast enhanced (DCE-MRI) or MR renography (MRR) have been investigated in animal models as well as in few human studies over the last decade.

DCE-MRI refers to the high temporal resolution imaging performed before and after administration of gadolinium contrast. MR renography (MRR) is a term used to describe one application of dynamic contrast- enhanced (DCE)-MRI, specifically, the use of gadolinium-based contrast agents for the noninvasive measurement of glomerular filtration rate (GFR).

This presentation will cover the following topics:

1. Basics Principles of DCE-MR Imaging 2. Acquisition scheme for DCE-MR/MRR: It requires a balance between anatomic coverage, spatial resolution, and temporal resolution. Topics to be discussed include 2D versus 3D volumetric coverage, population versus individual aortic input function (AIF), and recent advances in volumetric fast dynamic imaging. 3. Image analysis and extraction of appropriate physiologic parameters: Topics to be discussed include need for registration of dynamic data, relationship between signal-intensity and gadolinium concentration, and various published models to extract physiologic relevant parameters such as renal plasma flow (RPF), GFR, and tubular transit time. 4. Potential clinical application - MRR for GFR measurements - Renal tumor perfusion 5. Challenges to renal perfusion imaging in the clinic

www.esur2013.org 70 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 5: Tumor mimics and uncommon tumors of the GU tract Moderators: Takehiko Gokan, Ayşe Erden

WS5a Uncommon upper urinary tract tumors Parvi Ramchandani

WS5b Uncommon lower urinary tract tumors Lorenzo E. DerchiRadiolgy Department University of Genoa, Italy

The WHO and the Rare Cancers Europe websites define as rare tumors those with an incidence of fewer than 2/100.000 and those with a prevalence of less than 5 cases in a population of 10.000. Despite their rarity, there are more than 4 million people in the EU, about 22% of all cancer cases, diagnosed by rare cancers each year. This includes all cancers in children. Given the unusual occurrence of these tumors, patients with rare cancers are faced with particular challenges, including late or incorrect diagnosis, difficulties finding clinical expertise and accessing appropriate treatments, difficulties carrying out clinical studies due to the small number of patients, possible lack of interest in developing new therapies, high uncertainty in clinical decision-making, and the scarcity of available registries and tissue banks.

Furthermore, it is even more complicated: some cancers may be common in the general population, but rare in some subsets of patients (renal cell carcinoma is common in adults, but very rare in children), or may present special problems when in unusual locations (this may be the case for primary extragonadal germ cell tumors). Rare urological tumors are 2% of all rare cancers. Knowledge of these tumors is the most important point. Classifications are useful, since they are the means by which we attempt to better understand the biologic nature of disease; their ultimate goal being to separate patients into homogeneous groups whose neoplasms have similar natural courses and respond similarly to therapy. They are, however, mostly based on pathology and may be difficut to correlate with radiology findings. A basic clinico-radiological classification of uncommon GU neoplasms can be organized following two different parameters:

1) Size and symptoms: a. Those which are large and symptomatic (causing either specific or non-specific symptoms) b. Those which are seen during imaging performed for non-related symptoms c. Those which are too small to be detected by imaging and are seen by the pathologist in specimen obtained for other reasons

2) Imaging findings a. Unusual features (can suggest a possible unusual disease) b. Impossible to differentiate from common lesions (only pathology can show they are rare conditions) This workshop will discuss the imaging appearances of a variety of rare tumors, both benign and malignant, affecting the bladder, prostate, seminal vesicles and uretra, pointing at those findings which can possibly help to identify their nature preoperatively. It will be based on presentation of personal cases and of cases from the literature.

The diagnosis of these conditions is commonly regarded as difficult due to their unusual occurrence. In most cases, in fact, they are reported in the literature as case reports or small series only. Furthermore, the presentation will underline the role of the European Society of Urogenital Radiology as a network which can lead to increased knowledge of these tumors. The “Call for Scientific Cooperation” initiative can allow ESUR members to cooperate in collecting cases of rare cancers, thus allowing to study their appearances with various modalities, to understand their clinical course and, possibly, to have a positive impact on the therapeutic approach to these patients. Although such studies will be multicenter and retrospective and cannot rank with randomized controlled trials in terms of impact, they could fill an important niche in between anecdotal evidence and clinical trials in situations where a tumor’s rarity prevents prospective study. Hopefully, they will serve to shed sufficient light to advance the diagnosis for the unfortunate patients with these rare diseases.

71 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WS5c Pseudotumors Vikram Dogra

WS5d Retroperitoneal Tumors Sameh Hanna, MD. Professor of Radiology – Cairo University

The retroperitoneum is divided into three distinct compartments: the posterior pararenal space, bounded by the posterior parietal peritoneum; the anterior pararenal space, bounded by the transversalis fascia; and the perirenal space, bounded by the perirenal fascia. The anterior pararenal space is composed of pancreas and the right and left portions of the colon. The perinephric space is outlined anteriorly by Gerota fascia and posteriorly by Zuckerkandl fascia and contains the kidneys and adrenal glands.The small posterior pararenal space is bounded by the transversalis fascia posteriorly and the lateroconal fascia laterally. It contains two fat pads that lie ventral and posterolateral to the quadratus lumborum muscle. A fourth space surrounds the aorta and inferior vena cava. This space is limited laterally by the perirenal spaces and ureters and extends superiorly into the posterior mediastinum.

Most patients who have a retroperitoneal tumor present with abdominal swelling/increase in girth, abdominal discomfort, and most patients have a palpable mass.

Many benign lesions are discovered as an incidental finding during imaging for unrelated symptoms. Although the gastrointestinal and urinary tracts are often displaced, they are rarely invaded and gastrointestinal or urinary symptoms are unusual.

Primary retroperitoneal neoplasms are a diverse group of benign and malignant tumors that arise within the retroperitoneum but outside the major organs. Diagnosis of these tumors is often challenging for radiologists and consists of several steps, including determining tumor location (characterizing the retroperitoneal space and identifying the organ of origin) and recognizing specific features of various retroperitoneal tumors (evaluating patterns of spread, tumor components, and vascularity).

Primary retroperitoneal masses, which originate in the retroperitoneum but out¬side the major retroperitoneal organs, are uncommon and can be divided primar¬ily into solid and cystic masses, each of which can be further subdivided into neoplastic and nonneoplastic masses (Tables 1, 2). Of the primary retroperitoneal neoplasms, 70%–80% are malignant in nature, and these account for 0.1%–0.2% of all malignancies in the body.

CT and MR imaging are valu¬able in the evaluation of retroperitoneal masses, particularly in staging and the assessment of vascular invasion. Although a specific diagnosis might be difficult to determine because of over-lapping imaging appearances, the identification of certain characteristic imaging features, along with clinical and demographic information, may help in narrowing the differential diagnosis.

The presence of extensive necrosis in a ret¬roperitoneal mass, with contiguous involvement of a vessel, is highly suggestive of leiomyosarcoma.

Neurogenic tumors are seen commonly (a) along the sympathetic ganglia, which are located in the paraspinal region, and (b) in the adrenal medulla or the organs of Zuckerkandl (paraaor¬tic bodies). Less commonly, neurogenic tumors occur in other sites, such as the urinary bladder, abdominal wall, bowel wall, or gallbladder.

A fat-fluid (sebum) level and chemical shift between fat and fluid are pathognomonic of Teratoma. Retroperitoneal fibrosis is seen most commonly surrounding the infrarenal abdominal aorta and proximal common iliac arteries.

www.esur2013.org 72 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

References:

1. Clark MA, Fisher C, Judson I, Thomas JM. Soft-tissue sarcomas in adults. N Engl J Med. 2005;353:701– 711. 2. de Vreeze RS, de Jong D, Tielen IH, Ruijter HJ, Nederlof PM, Haas RL, van Coevorden F. Primary retroperitoneal myxoid/round cell liposarcoma is a nonexisting disease: an immunohistochemical and molecular biological analysis. Mod Pathol. 2009 Feb;22(2):223-31 3. Hueman MT, Herman JM, Ahuja N. Management of Retroperitoneal Sarcomas. Surg Clin North Am. 2008 Jun;88(3):583-97 4. Hughes MJ, Thomas JM, Fisher C, Moskovic EC. Imaging features of retroperitoneal and pelvic schwannomas. Clin Radiol 2005;60(8):886–893. 5. Neuhaus SJ, Barry P, Clark MA, et al. Surgical management of primary and recurrent retroperitoneal liposarcoma. Br J Surg. 2005;92:246–252. 6. Nishino M., Hayakawa K., Minami M., Yamamoto A., Ueda H., Takasu K. Primary Retroperitoneal Neoplasms: CT and MR Imaging Findings with Anatomic and Pathologic Diagnostic Clues. RadioGraphics 2003, 23, 45-57. 7. Rajiah P., Sinha R., Cuevas C., Dubinsky T.J., Bush W.H., Kolokythas O. Imaging of Uncommon Retroperitoneal Masses. RadioGraphics 2011; 31:949–976 8. Rha SE, Byun JY, Jung SE, Chun HJ, Lee HG, Lee JM. Neurogenic tumors in the abdomen: tumor types and imaging characteristics. RadioGraphics 2003;23(1):29–43. 9. Strauss DC, Hayes AJ, Thomas JM. Retroperitoneal tumours: review of management. Ann R Coll Surg Engl. 2011;93(4):275-80. 10. Tirkes T., Sandrasegaran K., Patel A.A., Hollar M.A., Tejada D.G., Tann M., Akisik F.M., Lappas J.C. Peritoneal and Retroperitoneal Anatomy and Its Relevance for Cross-Sectional Imaging. RadioGraphics 2012; 32:437–451 11.Van Roggen JF, Hogendoorn PC. Soft tissue tumours of the retroperitoneum.Sarcoma. 2000;4:17–26.

73 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 6: Adrenal Tumors Moderators: Nick Papanikolau, Gürsel Savcı

WS6a Comprehensive Imaging Algorithm of the Incidental Adrenal Mass Paul Nikolaidis MD, Northwestern University School of Medicine, Chicago, USA

With the proliferation of medical imaging, physicians are increasingly facing the diagnostic challenges associated with the discovery of an unsuspected mass on radiologic imaging. Among the most common “incidentalomas” are lesions discovered in the adrenal gland. Adrenal lesions are seen in approximately 4% of abdominal CTs performed for various reasons. The prevalence of these lesions increases up to 10% in the elderly.

With an increasing number of adrenal lesions being identified, it is imperative for the Radiologist to have a sound understanding of imaging characteristics and their implications. When an adrenal lesion is encountered, two questions must be answered: 1) is the lesion functional; and 2) is the lesion malignant. Despite being typically asymptomatic upon presentation, the Endocrinology literature recommends the patients undergo a clinical assessment that includes a hormonal work-up to evaluate for sub-clinical Cushing’s syndrome, pheochromocytoma, or hyperaldosteronism. This includes tests such as a 1-mg dexamethasone suppression test, plasma or urine metanephrine levels, and the ratio of plasma aldosterone concentration to plasma renin activity.

Improvements in imaging techniques, in CT and MR in particular, will very frequently allow for a definitive diagnosis in cases of benign pathology, obviating the need for any additional work-up. In indeterminate lesions, the radiologist should guide further workup or intervention on lesions that warrant treatment and differentiate them from the “leave alone” mass. With this in mind, the American College of Radiology developed recommendations for the management of “incidental findings”. The committee consensus was published as a White Paper to provide guidance. These guidelines promote greater consistency in recognizing, reporting and managing adrenal lesions. The anticipated benefits of such guidelines include reducing patient risk from unnecessary examinations, limiting costs of management, and providing guidance to radiologists concerned about litigation risk.

This presentation will briefly describe an algorithmic approach and review the various imaging techniques used to evaluate adrenal masses and their relative strengths and weaknesses. It will focus on the most prevalent adrenal pathologies and their typical imaging characteristics. A discussion of newer and developing techniques will be presented later in the Workshop Session.

WS6a The Role of PET-CT and DWI in adrenal imaging Gertraud Heinz-Peer

Positron Emission Tomography (PET) and PET-CT PET reaches beyond the morphologic level into the molecular characteristics of adrenal lesions. Knowledge of the physiologic appearance of adrenal glands in FDG PET is necessary to correctly identify pathologic processes. Whole body PET with 18-F-flourodeoxyglucose (18-FDG) allows malignant adrenal lesions to be recognized. Recent studies have reported false positive results as a result of 18-FDG uptake by pheochromocytomas and adenomas (Yun et al, 2001; Shimizu et al, 2003). 18-FDG PET also has the ability to detect metastatic lesions in non-enlarged adrenal glands, but its accuracy in this situation has not been fully evaluated. In addition, 18-FDG PET has the advantage of simultaneously detecting metastases at other sites.

PET-CT is currently the fastest growing imaging modality in the world. PET and CT are synergetic since PET offers high sensitivity and CT the necessary temporal and spatial resolution as well as other advantageous information. PET often detects the pathology, and CT helps to specify what is found and also contributes to the diagnostic power of the examination.

www.esur2013.org 74 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

In a study by Bagheri and coworkers (Bagheri et al, 2004) the maximum standardized uptake value (SUV) of normal adrenal glands ranged from 0.95 to 2.46. The average value of the maximum SUV and the mean SUV was calculated with 0.90 ± 0.15 and 0.83 ± 0.17, respectively, for the right adrenal gland, and 1.10 ± 0.15 and 0.946 ± 0.15, respectively, for the left adrenal gland. Usually, adrenal FDG uptake is considered to be of malignant origin when intensity is higher than liver uptake. Considering that normal liver tissue has an average mean SUV between 1.5 and 2.0, physiologic adrenal uptake might in some cases be in the range of malignant lesions.

Metser and coworkers (Metser et al, 2006) found that a maximum SUV of 3.1 or more is useful for differentiating malignant from benign adrenal lesions. The sensitivity and specificity was 98.5% and 92% using this semiquantitative threshold. The results by Metser further improved when the SUV threshold was combined with attenuation analysis from unenhanced CT. Additionally this study demonstrated that FDG uptake was not significantly different between lipid-rich and lipid-poor adenomas. In a study by Blake and coworkers (Blake et al, 2006) sensitivity was 100% for detecting adrenal malignant disease, the specificity was 94%. In this study SUV ratios (adrenal lesion SUV/liver SUV) have been shown to be more accurate in differentiating benign lesions from metastases than absolute SUVs. This is partially consistent with the investigation by Caoili and coworkers (Caoili et al, 2007) who found significant differences only in SUV ratios but not in absolute SUVs between adenomas and metastases to the adrenals. In this study a sensitivity of 96% and a specificity of 100% were demonstrated in the differentiation of malignant and benign adrenal lesions. However, it was suggested that interpretation should not solely be based on SUV measurements since this approach may produce false-negative findings in small (<1 cm) metastatic adrenal lesions or false- positive results in FDG avid adenomas (Kumar et al, 2004). Hemorrhage and necrosis are also known to cause false negative results. Furthermore, metastases from primary carcinomas which are non-FDG avid have been found to be false negative (Yun et al, 2001).

FDG accumulates not only in malignant tumor cells but also in activated inflammatory cells such as granulocytes and macrophages which can be mistaken for malignancy in patients with proven or suspected cancer. Both, acute and chronic infections including tuberculosis and autoimmune diseases might be associated with increased FDG uptake. Also postoperative healing scars and postradiation therapy lead to increased FDG-uptake. Moreover increased FDG uptake has been reported in adrenal adenomas, adrenal cortical hyperplasia without chronic inflammatory cell infiltration, and pheochromocytomas (Yun et al, 2001). FDG-PET-CT cannot differentiate between adrenal metastases, adrenocortical carcinomas, malignant pheochromocytoma, and lymphoma, each of which might present with increased FDG uptake. Brown fat deposition with increased FDG uptake in the retroperitoneum and periadrenal fat might also mimic a primary adrenal mass.

PET and PET-CT for Pheochromocytoma With the upcoming of PET and PET-CT the first tracer accumulating in organs specific for the sympathetic nervous system has been developed: 11C-hydroxyephedrine (HED). In a study by Trumpal et al. (Trampal et al, 2004) 12/13 pheochromocytomas were identified with HED-PET. Other tracers have been used for evaluating pheochromocytomas. Some reports indicate that 18F-flourodopamine (F-DA) is valuable for identification of primary and metastatic pheochromocytoma (Ilias et al, 2003). Furthermore, 18F-dihydroxyphenylalanine (F-DOPA), a precursor of dopamine, has been found to be of high sensitivity and specificity in PET imaging of pheochromocytoma. Hoegerle and coworkers (Hoegerle et al, 2002) demonstrated that F-DOPA had a higher sensitivity (100%) than 123I MIBG (71%) in the depiction of pheochromocytoma.

Magnetic Resonance Imaging Detection and Differentiation of adrenal lesions: the role of DWI DWI can provide insight into water composition within a tumor. Benign tumors tend to have proportionate increase of cells as well as intercellular space whereas malignant tumors usually have a disproportionate increase of cells as compared to interstitial tissue as well as disrupted cell membranes. These properties of malignancies result in selective restriction of diffusion of water molecules that may provide strong evidence for malignancy in an adrenal lesion. On the other hand, the lack of restricted diffusion may correlate with a benign or borderline neoplastic tumor. DWI of the adrenal gland can be performed using either breath-hold or non-breath-hold imaging sequences. Breath-hold imaging allows a target volume to be rapidly assessed. The images retain good anatomic detail and are usually not degraded by respiratory motion or volume averaging. Small lesions may be better perceived and the quantification of ADC is theoretically more accurate than with

75 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY a non-breath-hold technique. Most authors prefer to use a breath-hold single shot spin-echo EPI combined with parallel imaging and fat suppression.

A study by Miller et al. showed no significant difference between malignant lesions and pheos and neuroblastoma, no significant difference between lipid poor and lipid rich adenomas, and no correlation between percentage SI decrease and ADC values (Miller et al, 2010). They concluded that the ADCs were not useful in distinguishing benign from malignant adrenal lesions. Lipid-poor adenomas could not be distinguished from lipid-rich adenomas and all other non-fatty lesions of the adrenal gland with DWI.

In conclusion PET-CT has high sensitivity and specificity in differentiating benign from malignant adrenal lesions and thus contributes to the diagnostic power especially in oncologic patients. The role of MR DWI in characterizing adrenal masses has yet to be defined by further studies.

WS6c Malignant Adrenal tumors and Treatment Options Philip J. Kenney, M.D. University of Arkansas for Medical Sciences

Malignant neoplasm involving the adrenal glands is not uncommon, although benign lesions are more frequent. By educated use of all imaging modalities including CT, MRI, PET/CT and even MRI spectroscopy, in most cases diagnosis of adrenal malignancy can by made noninvasively. In limited circumstances adrenal biopsy may be indicated for histologic diagnosis, and is both accurate and safe. The commonest adrenal malignance is metastatic disease. Even when isolated to the adrenal, surgical resection of adrenal metastases is rarely effective, and systemic chemotherapy remains the mainstay of treatment. Other malignancies are less common such as adrenocortical carcinoma, malignant pheochromocytoma and lymphoma. As with metastatic disease, treatment of lymphoma is nonsurgical. With both adrenocortical carcinoma and malignant pheochromocytoma, surgical resection is an important treatment if the lesion is resectable, while systemic chemotherapy is standard for nonresectable lesions. I-131 Metaiodobenzylguanidine may be used in high doses to treat metastatic malignant pheochromocytoma.

Resection of adrenal tumors, both benign and malignant may be done with open procedures, but increasingly may done with less invasive methods including laparoscopic techiniques, adrenal arterial embolization, radiofrequency or cryo-ablation. These new techniques offer good results with lower morbidity but longer clinical trial studies will be needed to assess comparative effectiveness with standard cancer surgery.

www.esur2013.org 76 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 7: Renal Vascular Imaging Moderators: Süreyya Özbek, Anders Magnusson

WS7a Renal Doppler Ultrasound Diana Gaitini, MD

Unit of US, Department of Medical Imaging, Rambam Health Care Campus , Haifa, Israel Ultrasound Doppler of the renal arteries is a non-invasive, repeatable, relatively inexpensive and accurate test for the investigation of renovascular hypertension, most commonly caused by atherosclerotic diseases and fibromuscular dysplasia. It is as well a useful method for the diagnosis of further renovascular pathologies like renal artery occlusion, A-V fistula and renal vein thrombosis. In this presentation, the scanning protocol, normal anatomy and duplex criteria for normal renal Doppler and renal artery stenosis will be presented. Further renovascular pathologies will be discussed.

WS7b CTA and MRA Evaluation of Renal Artery Stenosis Ruhi Onur

Renal artery stenosis (RAS) is a potentially curable cause of renovascular hypertension. Estimated prevalance of RAS is 3-5% in the general population of hypertensive patients. Majority of renovascular hypertension is caused by atherosclerotic RAS. Fibromuscular dysplasia (FMD) is the next common cause of RAS. A screening test for RAS should have high sensitivity since missing renovascular hypertension may have serious consequences such as renal failure. Doppler ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA) and renal scintigraphy have been used as imaging techniques for detection of RAS.

Multidetector CTA enables precise visualization of the normal and variant anatomy of renal vasculature. A timed bolus and rapid injection rate are essential for high image quality at CTA. Volumetric data obtained at CTA demonstrate renal arteries in multiple planes and projections. CTA can also give additional information about the state of vessel wall, including mural calcification and plaques, post-stenotic dilatation, differences in the parenchymal perfusion and morphological alterations (atrophy, contour changes etc.) in the renal parenchyma. The sensitivity and specificity values of CTA in the diagnosis of RAS range between 94 - 100% and 79 - 97%, respectively (1-3). Reconstruction techniques of CTA such as multiplanar and curved planar reformation, maximum-intensity-projection (MIP), shaded-surface display, and volume rendering (VR) are helpful for accurate depiction and quantification of the arterial stenosis. MIP images reveal angiography- like appearance of the renal vasculature. Detailed evaluation with source and VR images is necessary in cases with severe atherosclerotic calcified plaques since RAS may be underestimated on MIP images. Volume-rendering images are also more useful in cases of overlapping vessels. MIP and VR show the best diagnostic interobserver agreement in quality and reproducibility of stenosis degree in the renal artery. Dynamic CTA can also determine the glomerular filtration rate with simultaneous assessment of morphology and function of the kidney.

Magnetic resonance angiography has become an increasingly used imaging technique in the evaluation of the renal vasculature. Development of ultrafast 3D sequences and parallel imaging enabled MRA to become a reliable test for the evaluation of the renal arteries, with excellent diagnostic accuracy in comparison with invasive DSA. A state of the art renal MRA can be performed with high spatial isotropic resolution, minimized acquisition time, sufficient FOV, homogenous and good enhancement on multiphasic examination, functional imaging and standardized reading criteria. Unenhanced MRA techniques which allow evaluation of the renal arteries and other visceral arteries include time-of-flight (TOF), and phase-contrast (PC) MRA techniques. PC-MRA not only gives anatomical information but also allows direct quantitative evaluation of flow dynamics with the intensity of flow signal being related to flow velocity. In both of these techniques, post processing with MIP or surface rendering is required for detection of areas of stenosis, which are seen as signal voids or areas of narrowing. Studies on unenhanced MRA have reported sensitivities ranging from 53-100% and specificities ranging from 47-97% in the diagnosis of RAS (4). A 3D steady state free precession sequence with in-flow inversion recovery is a new non-contrast MRA technique with a sensitivity of 91% and specificity

77 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY of 93% in detection of RAS (5). The shortcomings of non-enhanced MRA techniques are particularly long acquisition times, susceptibility to respiratory artifacts and overestimating of those stenoses which cause turbulent flow due to intravoxel dephasing phenomena. The sensitivity and specificity values of contrast enhanced MRA in detection of RAS range between 62–100% and 75–100%, respectively (6). However detection of hemodynamically significant lesions of distal, intrarenal, and accessory renal arteries may be difficult on MRA due to low spatial resolution compared to CTA. Flow profile changes with increasing degree of renal artery narrowing can be evaluated with the addition of PC-MRA flow measurements to a contrast enhanced renal MRA exam. The increased signal-to-noise ratio at 3 T MRI holds promise for high-spatial resolution MRA in evaluation of renal artery stenosis.

References 1. Rountas C, Vlychou M, Vassiou K, et al. Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT, angiography, Gd enhanced MR angiography and digital subtraction angiography. Ren Fail 2007; 29:295-302. 2. Echevarria JJ, Miguelez JL, Lopez-Romero S, et al. Arteriographic correlation in 30 patients with renal vascular disease diagnosed with multislice CT. Radiologia 2008; 50:393-400. 3. Fraioli F, Catalano C, Bertoletti L, et al. Multidetector-row CT angiography of renal artery stenosis in 50 consecutive patients: prospective interobserver comparison with DSA. Radiol Med 2006; 111:459-68. 4. Sarkodieh JE, Walden SH, Low D. Imaging and management of atherosclerotic renal artery stenosis. Clin Radiol 2013; 68(6):627-35. 5. Kramer U, Wiskirchen J, Fenchel MC, et al. Isotropic high-spatial-resolution contrast-enhanced 3.0-TMR angiography in patients suspected of having renal artery stenosis. Radiology 2008; 247(1):228–40. 6. Vasbinder GBC, Nelemans PJ, Kessels AGH, et al. Accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis. Ann Intern Med 2004;141(9):674–82.

WS7c Interventional procedures for hypertension Boris Brkljačić Department of Diagnostic and Interventional Radiology, University Hospital „Dubrava“, School of Medicine, University of Zagreb, Zagreb, Croatia

The objective of the workshop lecture is to present the options for the endovascular treatment of renovascular hypertension (PTA / stenting of renal arteries) and to discuss the method of renal denervation treatment for the resistant essential hypertension. Clinical significance of RVHT and natural history of untreated RAS will be presented. The options for the endovascular treatment of RVHT will be presented. The differences between renovascular hypertension caused by atherosclerotic renal artery stenosis and fibromuscuar dysplasia will be discussed, with regard to ethiology, imaging findings, and treatment options. Complications of endovascular treatment will be discussed, and some examples presented. The relation of endovascular treatment and best medical therapy will be discussed. The rationale and technique of renal denervation for the treatment of resistant essential hypertension will be discussed, and our own results presented.

WS7d Preoperative imaging assessment of renal donors and recipients Errol Colak

Renal transplantation represents the most effective long-term treatment for end-stage renal disease. As living donor renal transplantation and minimally invasive surgical approaches become the norm, the accurate and detailed preoperative imaging evaluation of potential renal donors will play an increasingly important role in the workup of these patients. Preoperative imaging facilitates the selection of appropriate renal donors and suitable kidneys, helps determine the ideal surgical approach through the detailed assessment of renovascular anatomy, and prevents donor complications.

This presentation will focus on the imaging evaluation of potential renal donors using multi-detector computed tomography (MDCT). MDCT is fast, non-invasive, offers high spatial resolution, and is viewed by many as the one stop imaging modality in evaluating potential renal donors. Commonly employed MDCT protocols will be reviewed as well as the anatomical variants and disorders of the renal parenchyma, arteries, veins, and collecting system that may preclude renal donation or impact surgical planning. In addition, the evaluation of potential renal transplant recipients will be briefly reviewed.

www.esur2013.org 78 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WS7e Vascular complications after renal transplantation Michel Claudon Professor of radiology University of Nancy, France

After renal transplantation, several disorders may cause early or long-term allograft dysfunction. They include medical complications (acute tubular necrosis, rejection, cyclosporine toxicity, and infection), urologic complications (obstruction and urinoma), post-surgery collection (hematoma, abscess and lymphocele), lympho-proliferative disorders and vascular complications. They are often associated and patients should be managed on multidisciplinary basis. The radiologist has a major role in the identification of complications, as clinical and biological signs are non-specific. Various imaging modalities can be used, but Ultrasound, Doppler and contrast-enhanced sonography (CEUS) are the first line modalities in the evaluation of a dysfunction of the allograft. The transplantation surgical protocol should be precisely known by the radiologist, including the type of allogaft (cadaveric, living donor), the side of the harvested kidney, the number of arteries and veins, potential abnormalities of the urinary tract and all specific pieces of information which may be necessary to properly interpret imaging data.

Vascular complications are the second most often detected, and may be found between 3% and 15% of the cases. At the acute phase, they include lesions of the renal allograft artery (torsion, dissection, thrombosis or false aneurysm), lesions of the renal allograft vein (thrombosis, torsion). Similar types of complications should be searched at the level of the feeding iliac artery of draining iliac vein. Cortical necrosis is a rare event, which is easily diagnosed by contrast-enhanced sonography. Mid-term or long-term complications include renal allograft stenosis, post-biopsy arterio-venous fistulas, and aneurysms.

A thrombosis of the renal allograft stenosis should be assessed when no flow within the kidney can be shown on Doppler mode and CEUS. The extent of the ischemic area depends on the number of arteries and site of thrombosis. This diagnosis should lead to a re-intervention in emergency which is the only chance to save the allograft. Renal vein thrombosis should be suspected when a “to and fro” appearance of the intrarenal Doppler waveform is displayed. A stenosis of the renal artery is mainly detected between 3 months and 2 years after transplantation, more frequently seen with cadaveric grafts than living donor ones. Several types of stenosis have been described depending on the context: rejection, post-surgery ischemia, king-king, arteriosclerosis. At Doppler, direct and indirect signs are similar to those described for a stenosis of a native kidney artery: increased velocities, turbulences, dampening in the downstream flow. There is no consensus on the significant threshold in systolic velocities but 2.5 m/s seems to be an effective value. Morphologic evaluation should be conducted with CT before angioplasty. The question remains the responsibility of a given stenosis in a decrease of the renal transplant: Doppler, CEUS, scintigraphy and fMRI may be used to asses a decrease in the downstream flow. Post-biopsy arterio-venous fistulas infrequently lead to renal dysfunction. They are easily detected on color Doppler, with a marked perivascular artifact at low PRF mode.

Cases of various vascular complications will be presented, to illustrate the interest and the potential of imaging modalities in their evaluation.

79 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 8: Male Genital Tract Tumors Moderators: Raymond Oyen, Lorenzo Derchi

WS8a Incidentally detected testicular tumors Wui Chong MBBS, MRCP FRCR University of North Carolina Chapel Hill, NC USA

Normal testicular anatomy The normal testicle measures between 3-5 cm long, 2-4 cm wide, and 3 cm in AP dimension. It is surrounded by the echogenic tunica vaginalis and albuginea. The tunica albuginea is not normally visible on ultrasound unless fluid surrounds the testicle. The rete testis is formed by the convergence of seminiferous tubules within the mediastinum of the testicle.

Benign testicular lesions. Ectasia of the rete testis is an idiopathic, benign condition associated with partial or complete obstruction of the efferent ductules, leading to cystic dilatation. This condition occurs most frequently in men older than 55 and is frequently bilateral, although unilateral occurrences are also seen. The characteristic finding of this lesion is a peripheral, elongated structure composed of multiple small, cystic or tubular structures that replace the mediastinum without causing significant mass effect. There are no calcifications, solid components, or flow on Doppler imaging Varicoceles may be extra-or intratesticular. Of the extratesticular varieties, the left side is more frequently involved. Vein diameter >3 mm and/or >1 mm of reflux during Valsalva are diagnostic of a varicocele. Infertility rates with varices range up to 33%, although variceal size does not correlate with likelihood of infertility.

Intratesticular simple cysts are common and have the usual ultrasound characteristics of benign cysts. Cysts of the tunica are common after trauma and frequently palpable by the patient. They may show calcification on ultrasound. Epidermoid cysts are also benign and account for 1-2% of resected testicular masses. These lesions show alternating rings of hyperechogenicity and hypoechogenicity on ultrasound, leading to the characteristic “onion ring” sign. Typically, epidermoid cysts show no flow on Doppler imaging, helping to differentiate them from the majority of other solid intratesticular masses. Tunical fibromas are benign, painless tumors that arise most frequently from the tunica vaginalis, but they can arise from the tunica albuginea, the spermatic cord, or rarely the testicular parenchyma. On ultrasound, these lesions are usually well-defined hyperechoic masses measuring 1 cm-3 cm in diameter centered on the tunica, although they rarely can appear poorly defined and hypoechoic. Posterior acoustic shadowing often signifies a dominant fibrous component. Scrotal tuberculosis most commonly presents with an enlarged, hypoechoic epididymis with or without calcifications. Testicular involvement can occur from epididymal extension and result in an enlarged hypoechoic testicle, sometimes with a nodular appearance. The appearance is often nonspecific, but the presence of hypoechoic epididymal enlargement with a testicular lesion favors tuberculosis over other infections.

Scrotal sarcoid is a rare complication of sarcoidosis, but epididymal and testicular involvement do occur. On ultrasound, single or multiple hypoechoic masses or a solitary echogenic mass involving the epididymis or testis can appear.

Polyorchidism is rare and can range from testicular duplication alone to duplication of the epididymis or the spermatic cord. These duplications are thought to be due to abnormal division of the embryonic genital ridge. Duplicated testicles can be recognized by their resemblance to a normal testis; a mediastinum testis is present. Patients have an increased risk of cryptorchidism, inguinal hernia, and testicular malignancy.

Congenital adrenal hyperplasia (CAH) is a group of inherited disorders that cause defects in the adrenal glands’ ability to produce cortisol from cholesterol, leading to increased levels of adrenocorticotropic hormone (ACTH). In patients with CAH, ectopic adrenal rest tissue is frequently identified within the testicles. In response to elevated levels of ACTH, this rest tissue enlarges and can present as a palpable mass. On ultrasound, these lesions are typically bilateral, hypoechoic, predominantly located peripherally, and show minimal mass effect. Additionally, a spoke-like pattern of vascularity may be present within the mass on color Doppler, but many of the masses will appear hypovascular or avascular.

www.esur2013.org 80 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Testicular microlithiasis is defined as >5 punctate, nonshadowing, intratesticular calcifications. Although there is an association between microlithiasis and testicular cancer, microlithiasis is very common – the prevalence is 5.6% (14.1% of African Americans). Longitudinal studies have shown that very few patients with microlithiasis will develop testicular cancer. Consequently, surveillance ultrasound for patients with microlithiasis is impractical and no longer recommended. Stromal tumors are derived stroma (Leydig cells) or from the sex cords (Sertoli cells). Leydig cell tumors are the most common and they constitute 5% of testicular tumors. Small tumors are hypoechoic while larger tumors are complex with cystic areas due to necrosis.

Malignant Testicular Lesions Testicular malignancy is the most common cancer in young men. Ultrasound’s sensitivity for testicular neoplasms is between 87.5% and 100%, with specificities between 55% and 66.7%. The overwhelming majority of primary testicular cancers are germ cell tumors. The commonest germ cell tumors are seminomas, mixed germ cell tumors, and teratomas. The ultrasound appearance of seminomas is usually a solid, hypoechoic mass; however, they can appear heterogeneous with microlithiasis or necrosis. 25% of patients will have distant spread of the disease via lymphatic or hematogenous routes. The primary tumor may outgrow its blood supply and involute in patients with systemic metastases. In this situation, known as the “burnt out” tumor, the primary lesion appears disproportionately small. Ultrasound examination may show a nonspecific hypoechoic or hyperechoic testicular lesion, which may be calcified, in the presence of large, systemic metastases.

Nonseminomatous germ cell tumors are the most common testicular cancer, usually presenting in patients <30 years old. In general, they are more aggressive than seminomas. On ultrasound, they are often heterogeneous, and show areas of necrosis, hemorrhage, or calcification.

Lymphoma is the most common secondary tumor of the testes. It most commonly occurs in patients >60 years, with non-Hodgkin’s lymphoma being the most frequent. It may appear on ultrasound as a diffuse, hypoechoic enlargement of the testis or as an avascular, hypoechoic, and intratesticular mass. Leukemic involvement is also common, as the blood-gonad barrier shields the testis from systemic chemotherapy. The ultrasound appearance often shows diffusely enlarged, hypoechoic testicles, frequently indistinguishable from lymphoma.

Testicular tumors can present with hemorrhage after relatively minor trauma. Scrotal hematoma can obscure an underlying neoplasm at the time of presentation. These tumors are better seen on follow-up sonography when hematomas would have been expected to resolve.

WS8b Extratesticular scrotal tumors Mustafa Secil, MD Professor of Radiology Dokuz Eylul University Faculty of Medicine Izmir, TR

Extratesticular scrotal area includes a variety of anatomical structures that include the scrotal wall, tunica vaginalis, epididymis, ductus deferens, spermatic cord, vascular, lymphatic and other supportive tissue of the testis. As for the testes, the principal method of examination for the extratesticular structures is also ultrasound (US). Ultrasound has the capability of nearly 100% for detection of lesions of that area. However, the specificity of the method is not as much high as its sensitivity and is around 70-90%, depending on the location and character of the lesions. Magnetic resonance imaging (MRI) may be an alternative or additional method of examination for lesion characterization. Computed tomography (CT) may be used for the staging work-up of malignant lesions to demonstrate lung metastasis.

Non-neoplastic lesions include the tunical cysts, epidymal cyst, spermatocele, fibrous pseudotumor, spermatic cord cyst, spermatic cord lipomatosis, and polyorchidism. Cystic lesions are easy to detect and diagnose as anechogenic masses on US, and in water signal intensity on all sequences of MRI. Lipomatosis seen as the echogenic thickening of the spermatic cord that may occur isolated or reactive process to accompanying hydrocele, MRI is very helpful for the diagnosis of lipomatosis by easy demonstation of fat content . In polyorchidism, the additional testis is in almost in similar echogenicity/intensity with the original testes. Fibrous pseudotumor is solid, homogenous lesion commonly difficult to diagnose pre-operatively.

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Neoplastic lesions may either be benign or malignant. Benign neoplasms are adenomatoid tumor, papillary cystadenoma and benign mesenchymal tumors, lipoma being the most common, followed by leiomyoma. Adenomatoid tumor appers as a homogeneous, avascular, well defined tumor at the juxta-testicular position. Papillary cystadenoma is a bunch-of grape like cystic tumor with papillary projections inside, that develop at the epididiymis and related to von Hipple Lindau disease in more than 60% of the patients. Lipoma has a characteristic appearance on US, with echogenic interlobular septations in a homogeneous, well defined, avascular, compressible soft tissue lesion. Malignant neoplasms are mesenchymal in origin, namely the rhabdomyosarcoma, leiomyosarcoma, liposarcoma, malignant fibrous histiocytoma (undifferentiated pleomorphic sarcoma) and other extremely rare ones. Metastases to the paratesticular region may also occur secondary to various primaries. Malignant tumors are commonly rapidly growing lesions that are big, sometimes huge in dimensions at the time of diagnosis. They are heterogeneous solid tumors that may contain cystic/necrotic areas, and they are commonly highly vascular lesions.

WS8c Penile Lumps Michele Bertolotto

Although in the western world penile cancer accounts for less than 1% of all male malignancies, it represents a significant health problem in developing countries, where it accounts for 10-20% of all malignancies in men. In 95% of cases penile malignancies are squamosus cell carcinomas. Glans is the most common location (48%), followed by prepuce (21%), glans and prepuce (9%), coronal sulcus (6%), and shaft (< 2%). The clini- cal presentation of penile squamous cell carcinoma is variable and may range from an area of induration or erythema to a non-healing ulcer or a warty exophytic growth. The differential diagnosis includes precancer- ous lesions and a variety of inflammatory conditions. Diagnosis is confirmed with biopsy. Imaging is indicated for staging purposes.

Among the remaining 5% of primary penile malignancies sarcomas are the most frequent, followed by mela- noma, basal cell carcinoma, and lymphoma. Kaposi’s sarcoma increased in frequency with the onset of AIDS.

Penile hemangioma is the most frequent benign tumor of the penis. Giant cavernous hemangioma may in- volve the entire glans and a variable portion of the corpora cavernosa, scrotum and perineum. Metastatic cancer to the penis usually occurs in patients with a known malignancy in an advanced stage to prostate, bladder, lung, malignant melanoma, colon and kidney.

Imaging Squamous cell carcinoma

At ultrasound the lesion is usually hypoechoic with poor vascularization. Increased vascularity can be recog- nized in inflammed lesions. Ultrasonography is more accurate than clinical examination for measuring the lo- cal extent of the tumor. Frank infiltration of the corpora cavernosa is identified as an interruption of the echo- genic interface of the tunica albuginea. In advanced penile cancers CT has a role for identification of distant metastatic deposits. It is also indicated in patients with lymphoma to check for presence of other localizations of the disease.

MR imaging is the gold standard modality for staging primary penile malignancies. The depth of tumor in- vasion and involvement of the tunica albuginea, corpora, or urethra can be determined. Different imaging protocols can be used. At least an axial T1-weighted and axial, sagittal, and coronal T2-weighted sequences should be produced. If gadolinium is administered, fat-saturated T1-weighted images should be obtained on the 3 planes before and after contrast administration. Axial T1-weighted images of the pelvis are obtained using a pelvic coil to look for inguinal and obturator lymphadenopathy. Intracavernosal PGE1 injection is rec- ommended. In general, squamous cell carcinoma is hypointense or isointense to the corpora on T1-weighted images, and hypointense on T2-weighted images. T2-weighted and gadolinium enhanced T1-weighted im- ages are the most useful sequences in defining the local extent of the disease.

In patients with penile cancer bone scintigraphy is indicated when symptoms suggest possible metastatic involvement. PET/CT with 18F-Fluorodeoxyglucose (FDG) is a very promising tool in detection of nodal me- tastases in patients with penile cancer. The major limitation is inability to detect micro-metastases, due to insufficient spatial resolution.

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Imaging other penile tumors

Ultrasound appearance of tumors different from squamous cell carcinoma is non specific. Giant cavernous hemangioma is heterogeneously echogenic with multiple hypoechoic lacunae, and with high signal intensity on T2-weighted MR images. The lesion may involve portions of the corpora, or spread in the soft tissues out- side the penile bodies, involving the scrotum and the perineum. MR imaging is indicated in large hemangio- mas to assess the extent of the lesion.

Neurilemmoma presents as a well-defined, hypoechoic rounded, highly vascularized mass. Schwannoma may present as a heterogeneous extracorporeal mass with well defined margins, high signal intensity on T2- weighted MR imaging, and strong enhancement on contrast-enhanced T1-weighted images.

Epithelioid sarcoma may present as a solid mass with multiple focal calcifications infiltrating the corpora cavenosa. It is omogeneously isointense on T1-weighted images and inhomogeneously isointense or hy- pointense on T2-weighted images. Homogeneous or heterogeneous enhancement is observed after contrast agent injection.

Kaposi’s sarcoma usually presents as a heterogeneously hypoechoic vascularized mass with ill-defined mar- gins characterized at MR imaging by relatively strong tumoral enhancement after contrast material adminis- tration.

Lymphoma is an isoechoic or relatively hypoechoic hypervascularized lesion often with infiltration of the cor- pora cavernosa. It is usually hypointense on T1 weighted images and hyperintense on T2 weighted images with variable, usually prominent enhancement.

Primary melanoma is often hyperintense on both T1- and T2-weighted images with strong enhancement.

Penile metastases can present with nodular deposits or direct infiltration of the penile shaft by adjacent pri- mary malignancies. Invasion of the tunica albuginea and replacement of the cavernosal tissue by enhancing tumor is recognized in patients with infiltration of the shaft from adjacent cancer.

Non-neoplastic penile lumps

Beyond inflammatory and traumatic lesions, and circumscribed cavernosal fibrosis, penile cysts and partial segmental thrombosis should be considered in the differential diagnosis of penile lumps.

Median raphe cysts appear at ultrasound as simple cysts, with typically anechoic content. Sebaceous cysts are homogeneously hypoechoic or relatively echogenic. Epidermoid cysts appear as ovoid or lobulated masses with well-defined margins, relatively echogenic content with hypoechoic foci. Calcifications are oc- casionally identified. At MR imaging epidermoid cysts present with well circumscribed masses lacking inter- nal contrast enhancement. On T1-weighted images signal intensity is similar or higher compared to muscle, while signal intensity is high on T2-weighted images. Irregular low-signal intensity areas are recognized on both T1- and T2-weighted images.

Persistent pain and induration of the proximal portion of the penile shaft may result from partial segmental thrombosis of a corpus cavernosum. At CEUS, a heterogeneously hypoechoic lesion with no vascularization is identified in the involved portion of the corpus cavernosum. At MR imaging, the lesion does not enhance. Signal intensity characteristically varies with time on both T1- and T2-weighted images, depending on oxy- genation and degradation of its contained hemoglobin.

83 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WS8d Testicular sparing surgery for sequential bilateral testicular tumors A.Erdem Canda, MD Associate Professor of Urology Member of Robotic Urology Group (Young Academic Urologists-YAU, European Association of Urology-EAU) Yildirim Beyazit University School of Medicine Ankara Ataturk Training and Research Hospital Department of Urology Ankara, Turkey

Testis tumors might involve both testes in males either synchronously or metachronously. The standard treatment of choice of testicular tumors is inguinal orchiectomy. In bilateral testis tumors, bilateral inguinal orchiectomy would cause male infertility, sexual dysfunction and androgen replacement therapy. This situation particularly might have a negative impact on the psychology of young men. Therefore, testis sparing surgery (TSS) could be performed in suitable patients with sequential bilateral testicular tumors with oncological safety and preserving functional outcomes. In sequential bilateral testicular tumors, tumors less than 20 mm in size that are not close to the rete testis are suggested as candidates for TSS. Before starting the TSS procedure, we apply spermatic cord clamping (15 minutes with ice slush) under cold ischemia. Following removal of the tumor, intraoperative tumor bed biopsies should be taken for intraoperative pathologic evaluation. It has been shown that frozen section examinations can accurately diagnose testicular cancer. Postoperative radiotherapy to the remaining testis could be administered to eradicate carcinoma in situ (CIS) thus prevent tumor recurrence. Local cancer recurrence seems to be higher in series of patients with a higher incidence of CIS in the testis. Residual tumor in the residual testis is another major risk factor for local recurrence. The patients should be followed up meticulously in the postoperative period. In the present talk, a 10-minute surgical video of TSS that we performed in one of our patients is shown and outcomes of the current literature on TSS are summarized.

Key Words: bilateral testicular tumors, testis sparing surgery, partial orchiectomy

References:

1. Canda AE, Atmaca AF, Ozdemir AT, Akbulut Z, Balbay MD. Testis sparing surgery for sequential bilateral testicular tumors. Can J Urol. 2009 Jun;16(3):4677-81. Review. 2. Kirkali Z, Tüzel E, Canda AE, Mungan MU. Testis sparing surgery for the treatment of a sequential bilateral testicular germ cell tumor. Int J Urol. 2001 Dec;8(12):710-2.

www.esur2013.org 84 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 9: Imaging of infectious diseases of GU tract Moderators: Adnan Kabaalioğlu, Tarek Eldiasty

WS9a Hydatid Disease Okan Akhan, MD Prof. of Radiology

Hydatid disease is a parasitic infestation caused by Echinococcus granulosus. Although the most affected organs are liver and lung any organ or tissue can be involved by the disease. Renal involvement is rare, generally single and located in the cortex of the kidney. It incidence is between 2 and 4% of all cases. Renal hydatid cysts is generally diagnosed incidentally as they can remain asymptomatic for many years. The main clinical symptom is lumbar pain seen up to 65% of the patients. renal cystic mass, hematuria and hydatiduria are the main features of the disease. No serological test is pathognomonic for the diagnosis of renal hydatid cysts as the ones located in the other organs.

Imaging modalities (US, CT and MRG) play an important role for the diagnosis of renal hydatid disease. The most important imaging modality is US which also helps to make differential diagnosis between hydatid cyst and the other cystic masses of the kidney. Although surgery is a traditional method of treatment, surgical treatment of renal hydatid cysts usually result in partial or total loss of the involved kidney. It is also ascociated with considerable postsurgical complications. Therefore percutaneous management of renal hydatid cysts have been a treatment of choice in last two decades as the hydatid cysts located in liver and some other organs. The main indication for percutaneous treatment of hydatid cyst includes “viable cysts”. Different types according to Gharbi or WHO classifications are treated by different percutaneous techniques which is defined to be “stage-specific approach”. According to WHO classification, CE 1 and 3A are considered to be most appropriate for PAIR; CE 2 for Catheterization technique or Modified catheterization technique (MoCaT or PEVAC); CE 3B for MoCaT. No treatment is necessary in patients with CE 4 and 5 which are managed by “Wait and Watch approach”.

Three different techniques are used in percutaneous treatment of hydatid cysts. The first one is; the PAIR technique described by Ben- Amour et al. in 1986. PAIR is the abbreviation of Puncture, Aspiration of cyst content, Injection of hypertonic saline solution, and Reaspiration of all fluid. The second one is the Catheterization technique with hypertonic saline and alcohol described by Akhan et al. in an experimental study in sheep in 1993. The third one is called as modified catheterization techniques such as MoCaT or PEVAC. After standard steps of catheterization techniques a 14F catheter is inserted into the cavity to evacuate all the content. Aggressive irrigation with isotonic NaCl is employed via the catheter to evacuate all the cavity content.

Percutaneous treatment of renal hydatid disease avoids the morbidity of renal surgery and preserves the residual function of the kidney. In the published series with small number of cases in the literature the cure rate is over 90%. The major complication is the development of abscess in the cavity which can be treated percutaneously as well.

Percutaneous treatment of hydatid renal disease is an effective and safe procedure with its unique advantages (e.g., shorter hospital stay, low complication rate). Today, the percutaneous approach has an important role in treatment of hydatid cysts not only in the liver but also in the kidney. Therefore it must be first treatment option whenever it is indicated.

WS9b Non-hydatid parasitic infections Mohamed Abou El-Ghar

There are many Parasites that can involve the genitourinary tract; the relatively common group includes schistosomiasis, echinococcosis, and filariasis while there are many other parasites that rarely involve the GU tract such as malaria, leishmaniasis, trypanosomiasis, babesiosis, toxoplasmosis, trichinosis, dioctophymiasis, microsporidiasis, sparganosis, fascioliasis, genital amebiasis, toxocariasis, strongyloidiasis, and genital flagellates. It is a heterogeneous group of infection but it has some common imaging features.

85 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Parasitic disease may be due to protozoa or helminthes. Heliminths infection of the urinary tract is more common than protozoa. Generally helminthiasis is a highly prevalent disease worldwide and it is endemic in developing countries and places where sanitation is poor, but it also occurs in non endemic areas because of immigration and travel.

Radiologic imaging and also awareness with the geographic distribution, transmission cycle, and characteristic and atypical manifestations of common helminthic diseases at abdominal imaging with radiography, computed tomography, magnetic resonance imaging, and ultrasonography may help narrow the differential diagnosis.

We will present the imaging features of the non-hydatid GU parasitic infection with special focus on the relevant common types including bilharzial and filarial infection and also the imaging features of their complications such as bladder cancer and the chyluria.

WS9c Acute and Chronic Pyelonephritis Jeffrey H. Newhouse, M.D.

This presentation will deal with issues in imaging bacterial infections of the urinary tract in adults. It will touch briefly on classic radiologic findings, and include both useful analytic suggestions and discussions of common misunderstandings.

Whom to image: Ideally, imaging should be used only when it has a reasonable likelihood of altering management; since in most cases of uncomplicated infection standard antibiotic therapy is appropriate and sufficient, these cases do not need imaging. According to the American College of Radiology Appropriateness Criteria, however, patients who have diabetes mellitus, other reasons to be immunocompromised, history of stones, prior renal surgery or who fail to respond to therapy, should be investigated; for them, CT with contrast is highly indicated, and ultrasound and MRI moderately indicated. Since obstruction, stones and large renal or perirenal abscesses often require intervention, and are subject to reasonably reliable diagnosis with ultrasound, which is in turn safe and relatively inexpensive, it may be reasonable to lower the threshold for using ultrasound, especially for severely ill patients

Imaging manifestations of acute pyelonephritis: One hallmark of acute pyelonephritis is its patchy distribution; it is almost never a bilateral disease which produces diffuse uniform renal abnormalities, and is unilaterally diffuse and uniform only if there is ureteral obstruction. CT without IV contrast is not highly sensitive for acute pyelonephritis, although occasionally renal swelling and perinephric inflammation may be visible. Contrast-enhanced CT reveals patchy regions of diminished early enhancement, sometimes with striation; these regions may demonstrate persistent enhancement hours after contrast administration. These findings may resolve more slowly than clinical symptoms and infected urine abate. Ultrasound is less sensitive for mild focal pyelonephritis than contrast-enhanced CT (although contrast-enhanced ultrasound is more sensitive); the classic findings described are patchy regions of increased echogenicity, although regions of decreased sensitivity may also appear. MRI findings include focal loss of intensity on T1-weighted images, increased intensity on T2-weighted images, focal restriction of diffusion and diminished and inhomogeneous enhancement with gadolinium. Differential diagnostic possibilities include focal acute ischemia, contusion and even infiltrating neoplasm.

Renal and perirenal abscesses: These display the common imaging characteristics of abscesses in other locations. They only rarely appear as sequelae of acute pyelonephritis; when they do, they often indicate the coexistence of other conditions, such as vasculitis and septic emboli. Superinfected cysts and infected obstructed calyceal diverticuli may have appearances so similar to abscesses that their pre-existing anatomy may remain obscure. Perirenal abscesses are often infected prerenal urinomas; when they are found, obstruction should be carefully excluded.

Emphysematous pyelonephritis: Gas-forming organisms (usually E. coli, but also Klebsiella, Aerobacter and Proteus) may infect the kidney and produce gas in a variety of patterns in the renal parenchyma, perinephric space and within the collecting system. The old adage that every patient with this disease needed immediate nephrectomy is proving often not to be true. Some authors find that distribution and amount of gas predict outcome; others find that the clinical picture is more accurate than radiologic findings for prognosis.

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Xanthogranulomatous pyelonephritis (XGP): The classic imaging findings of XGP consist of an enlarged non-functioning kidney with calcification and exuberant perirenal fatty proliferation. In fact, XGP is a histologic finding consisting of cells (large lipid-laden macrophages) which form in response to chronic pyogenic infection. The commonest setting for this is long-standing obstructive pyonephrosis, usually due to a calcified stone, but it may occur with a chronic renal or perirenal abscess as well, and these conditions appear the same whether or not they are accompanied by XGP. It is less important to make a specific diagnosis of XGP than it is to assess residual renal function after decompression or drainage when deciding upon surgical management.

Chronic pyelonephritis: The name of this condition suggests that it denotes long-standing or repeated renal infection, which is misleading. The phrase is usually applied to a specific imaging or gross pathologic constellation of findings, which consist of focal coarse cortical renal scars accompanied by associated calyceal blunting or dilatation, often occurring without simultaneous clinical or laboratory symptoms. Calyceal blunting may be demonstrated by urography, CT or MR; these and ultrasound may reveal the scars. Hypertrophy of remaining tissue occasionally produces mass-like cortical swellings; these can be differentiated by showing that their CT or MR enhancement is identical to normal renal cortex in other regions.

There are a number of etiologies for this condition. In children, it is usually caused by prior or concurrent vesicoureteral reflux (and therefore often more appropriately identified as reflux nephropathy). When encountered in middle-aged or elderly adults, other causes are usually responsible. Although these include prior episodes of acute bacterial pyelonephritis, acute pyelonephritis more often heals without scarring; the commonest cause of chronic pyelonephritic scarring is calyceal stone disease. Trauma (surgical and other), focal renal ischemia and focal radiation nephritis may also be causative. Although of course the scars never resolve, determining the etiology may permit management to avoid further renal loss.

WS9d Infectious diseases of the male and female genital tract. Gabriele Masselli MD and Gianfranco Gualdi MDRadiology Department. Umberto I Hospital, Sapienza University. Rome Italy

Infectious diseases of the male and female genital tracts are uncommon, but when they do occur, urgent or emergent diagnosis and treatment are necessary. Infectious conditions of the male genitalia are primarily epididymitis and epididymo-orchitis, are well evaluated at ultrasonography (US), and their key findings include heterogeneity and hyperemia. pyocele and abscess may also be seen at US, but MR is useful for a better evaluation. Fournier gangrene is best evaluated at computed tomography, which depicts subcutaneous gas. Pelvic inflammatory disease (PID) refers to infection and resultant inflammation of the upper female genital tract, including the endometrium, fallopian tubes, and ovaries. PID is a common medical problem, affecting nearly 1 million women each year.

Transvaginal US was performed in the emergency room and treatment decisions are usually based on this information.

MR imaging is more accurate than transvaginal US in the diagnosis of PID. MR and CT findings in early PID include obscuration of the normal pelvic floor fascial planes, thickening of the uterosacral ligaments, cervicitis, oophoritis, salpingitis, and accumulation of simple fluid in the endometrial canal, fallopian tubes, and pelvis. As the disease progresses, this simple fluid may become complex and the inflammatory changes may progress to frank tubo-ovarian or pelvic abscesses. Reactive inflammation of adjacent structures is common and can manifest as small or large bowel ileus or obstruction, hydroureter and hydronephrosis, right upper quadrant inflammation (Fitz-Hugh-Curtis syndrome), or peritonitis.

Learning objectives of this lecture are to describe the key imaging features of Infectious diseases of the male and female genital tract and discuss the imaging signs to differentiate the non-infectious disease that may mimic infectious disorders.

Radiologists must quickly and efficiently diagnose or rule out infectious conditions of the male and female genitalia to facilitate prompt and appropriate treatment.

87 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Workshop 10: Infertility Moderators: Parvati Ramchandani, Jo McHugo

WS10a How to manage infertile couple: gynaecologist’s perspective Bülent Tıraş

WS10b Expanding role of imaging as a guidance to renal sparing treatment and its complications” Prof Francesco M. Danza Radiology, chief of Emergency section Dept of bioimaging and radiological sciences Università Cattolica del S Cuore, Rome Italy

“There was a time when a renal cancer was just a renal cancer: a solid enhancing mass in the kidney that required no further description and was removed with a radical nephrectomy. As radiologists, we staged the mass according to whether it invaded the renal capsule, whether enlarged lymph nodes were present, and whether the renal vein and inferior vena cava were involved and then we went on to the next case, leaving histology to the pathologists” Peter L. Choyke from Radiographic , 2006. Now the scenario is dramatically changed: two different facts contributed to change the management of renal tumors: first the ability of urologists to resect renal lesions with respect of renal parenchyma: partial resections, enucleations and ablations are today alternative to nephrectomy and represent the preferred surgical treatments for the smaller tumors. When nephron sparing surgery (NSS) is feasible, its results vs radical nephrectomy do not differ in terms of oncologic outcome . Second the diffusion of MDCT with high spatial and temporal resolution, offered a beautifull demonstration of renal anatomy, from vascular structures to renal lodge details with emphasis for functional considerations. The possibility to detect and characterize small renal masses under ten millimeters is now expanded. In such a scenario Radiology has increased its possibility to respond to the questions coming from the clinical counterpart in order to realize the best treatment with the maximum sparing of parenchyma.

The role of imaging is to day expressed at different levels: detection of small renal masses, solid or cystic, is increasing, being the diagnosis of renal tumors done, in many cases, during imaging studies performed for non-renal symptoms. And also the number of US, CT and MR studies performed for various abdominal symptoms is increasing: many are the renal lesions seen during MR evaluation of the spine. There is an increase of numbers of diagnosed and treated RCCs, but there is also increased survival for these patients, and imaging has played a key role. Today, most renal tumors are discovered at T1 or T2 stage. Before the development of MDCT, lesions < 3 cm were 5%; they are now between 9% and 38%. Tumor stage at diagnosis is one of the most important prognostic factors in Pts with RCC.

RCCs are not one single tumor: malignancies of different histologic types origine from different cells within the kidney: Clear cells, Papillary, Chromophobe, Bellini type, Mesenchymal tumors. Benign solid masses are Oncocytoma, Mesenchymal tumors, AML, Leiomyoma, Juxtaglomerular tumor, Fibroma, Lipoma, Hemangioma. Is it important to differentiate them preoperatively because benign solid nodules are demonstrated in 20-30 % of all resected lesions <3 cm: oncocytomas and AMLs are the most common. To recognize them and avoid unnecessary surgery is a fundamental job for imaging. It is easy to recognize an AML when there is easily-visible fat in it, more critical is the diagnosis in Fat-poor tumors.

It may even be possible to differentiate tumors of different histology within the same kidneys. Multicentricity and bilaterality of RCC is considered uncommon (2%-5% of patients). Asynchronous, contralateral tumor development is seen in 2% of patients who undergo radical nephrectomy for RCC. Nevertheless, multicentricity, which includes microscopic foci of RCC, is reported in up to 25% of radical nephrectomy specimens. These numbers will likely change with improved detection. The clinical behavior and prognosis is quite different: Clear Cells Ca – 65% of all lesions: 90% metastases versus Papillary and Chromophobe Ca – 25% of all lesions: 10% metastases. 4%-5% of RCCs have a hereditary association. Hereditary tumors tend to be multiple, bilateral, and develop at an earlier age in both sexes and multicentric tumor development should prompt consideration of a hereditary condition. The list of hereditary associations is growing and all tumor subtypes are represented.

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Evaluating morphological and functional aspects as structure, vascularization, and necrosis characterization is frequently successfully obtained. High enhancement and heterogeneity significantly associated with aggressive lesions. A confounding factor is the presence of areas of necrosis in large, less aggressive tumors. The new possibility of perfusion (CT) and diffusion (MRI) expand very much the benign-malignant differential diagnosis.

Differentiation may help physicians stratify individualized treatment, estimate probability of tumor recurrence, design rational follow-up regimens and provide patient counseling; furthermore, it may be potentially useful in clinical trials.

Recently some methods are proposed (“C-index”, “Padua” and “Renal”) to guides surgical planning and provide clues to best surgical approach; both are prognostic factors to complications: all these methods are based on imaging able to furnish preoperative knowledge of renal vascular anatomy and tumor location (spatial localization) and staging. For example Patients with PADUA score 6 – 7 had significantly less complications than those with higher scores. So an accurate preoperative imaging is the key factor in deciding NSS feasibility and in guiding “how to do” it.

Percutaneous biopsy has not been frequently employed in patients with renal masses. “Classical” indications to biopsy of renal masses are: renal vs metastatic disease in patients with known extrarenal primitive neoplasm; dd with abscess, renal infection or lymphoma; histologic confirmation of a primitive renal tumor with disseminated met disease or huge, retroperitoneal, non resectable mass. Two main factors have recently increased the role of percutaneous biopsy of renal masses to provide a tissue diagnosis before a therapeutic decision: imaging detection of a high number of asymptomatic small solid renal nodules (19-27% benign) and the development of focal ablation techniques for renal tumors. There are still some diagnostic problems: oncocytomas seem difficult to differentiate from Chromophobe Carcinomas (need for special stainings, need for large/cutting needles). Percutaneous biopsy can be problematic in patients with cystic renal neoplasms (limited tissue is often aspirated). Hemorrhagic fluid and atypical cells found also in benign lesions. Up to 16% of tumors have internal heterogeneity, with different Furham grades.

The new nephron sparing surgery have expanded the spectrum of complications, due to the different approach to the renal parenchima and its excretory system, which remain in place and can be source of many adverse events in postoperative period. As in conventional surgery radiological imaging is the gold standard for control and follow-up (hematoma, urinoma, vessel thrombosis, abcess).

Each one of these points is important for the success of treatment and now radiologist have the opportunity to enter in the multidisciplinary group of renal tumor management with urologists and oncologists.

WS10c How to manage infertile couple: Urologist’s perspective Prof. Dr. Ateş Kadıoğlu, Dr. Emre Salabaş Urology Department, Istanbul Medical Faculty

A couple is defined as infertile when they fail to achieve pregnancy after a sexually active year. Around 15% of the couples apply for medical counsel because of infertility. The ratio of male infertility is reported as 50% in these couples. In addition 30-40% of patients are diagnosed with idiopathic male infertility which has only abnormal semen parameters. The objective of an urologist is to the restoration of this male infertility to obtain pregnancy. Meanwhile female should be simultaneously examined in the appropriate section.

The primary/secondary discrimination, duration are important prognostic factors for contraception as well as the semen analysis results and female fertility status. A complete assessment of history, physical exam and laboratory tests should be performed in order to make a correct diagnosis which is a key stone of treatment. The elimination of urogenital diseases of males is a necessary part of this assessment. Only one semen analysis is required if its normal according to WHO criteria but a subsequent analysis should be added in case of abnormal results. New WHO criteria for semen volume, sperm concentration and progressive motility were stated as >1.5 cc, 15 million/cc and 32% respectively. Oligozoospermia and asthenozoospermia terminology are used for concentration and motility problems while teratozoospermia describes normal sperm morphology lower than 4%.

89 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Although the infertility may be due to a pathology in the hypothalamic- pituitary axis or duct obstruction, the majority of the cases occurs as results of testicular failure. The reason of this failure may be due to congenital reasons such as anorchia, cryptorchidism, genetic abnormalities or acquired ones like trauma, infection, torsion, exogenous factors and systemic diseases/malignancies. High FSH levels indicate testicular failure as the reason of infertility. In these cases testicular biopsy is the best diagnostic tool in which the retrieved sperm should be kept with cryopreservation in order to use them for ICSI. For patients who would undergo surgery for NOA (non-obtructive azoospermia), genetic counseling should definitely be offered. In optimum condition using appropriate surgical techniques (mTESE) and treatment, the sperm retrieval and pregnancy success of ART for NOA patients are 60 and 30-50% respectively. mTESE: Requirement of micro surgical skills, greater learning curve and longer operation time is balanced by much higher SRR for this technique. In addition preservation of testicular tissue and vascular structure are further advantages. The SRR is correlated with seminifer tubule diameters with a threshold value of 110 microns. This rate was demonstrated to be 84% and 36% for >300 micron and <300 micron diameters of seminifer tubule respectively. Up to 60% sperm retrieval rate was reported for mTESE which is superior to its conventional counterpart (23%). The predictive factors for SRR are accepted as experience of the surgeon, duration of the operation and histopathology of testis.

Karyotype and Yq microdeletion analysis should be performed for infertile males with sperm concentration lower than 10 and 5 million respectively. Patients with Klinefelter might require androgen replacement as the age progresses and a routine endocrine follow-up should be performed after testicular biopsy. The presence of vas deference abnormality might indicate cystic fibrosis and appropriate genetic tests should be performed. These tests should be seconded by a genetic counseling in case of an abnormal result.

Varicocele is accepted as a progressive disease effecting the fertility of male since his adulthood (25%). Varicocelectomy is the most common surgery performed for the sperm production improvement. The surgery is not indicated for men with subclinic varicocele and normal semen parameters. After the surgery the prominent improvements are observed in motility and morphology with a higher chance of success in men with >10 million sperm/ml. The spontaneous pregnancy odds ratio after varicocelectomy was reported as 2.63 in patients with palpable varicocele and abnormal semen parameters.

Obstruction is the secondary reason of azospermia and infertility (20%). The pathology might be in the proximal or distal part of seminal ducts;and due to a congential or acquired reason. While epididymal obstruction is the most common reason of OA (30-67%), intratesticular obstruction (15%), vas deferens and ejaculatory duct obstruction are the other causes of this disease. Low semen volumes, normal FSH values and testicular size are important clues of OA.

Surgery to allow sperm delivery are applied to patients with proximal and distal seminal duct pathologies. Existence of sperm in ejaculate to allow spontaneous pregnancy is the main objective of this surgery. Microscopic vasavasostomy and epididymovasostomy are the elementary surgeries of this subject but technological developments such as robotics may be applied as developed. Microscopic vasovasostomy was reported to have patency and pregnancy rates of 92% and 53% with an interval of 3 years. For vasoepididymostomy patency and pregnancy rates of 48-63% and 21-45% had been reported with a mean interval of 16 months. TUR-ED is the endoscopic technique which is performed in distal duct pathologies. Sperm parameter improvement had been reported up to 94% in men with distal duct obstructions. For reconstructive surgery, epididymal sperm acquirement and cytopreservation of it should be performed.

In patients inappropriate for reconstructive surgery, techniques such as MESA and TESA may be performed. In MESA (Microscopic Sperm Aspiration) the number of gathered sperm is sufficient for both ART and cryopreservation. The SRR and pregnancy rates are 90% and 14-66% respectively. The ART success rates of epididymal sperms are similar to testicular ones.

Whereas TESA (Testicular sperm aspiration) become reserved for obstructive azoospermia subsequent to the introduction of TESE. The general SRR for OA and NOA patients are 100% and 27% respectively. Although adequate number of sperms are gathered for ART, cryopreservation may not be possible all the time. This technique is not preferred anymore because of possible vascular injury and insufficient sperm numbers.

www.esur2013.org 90 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

WS10d Role of Imaging in Male Infertility Pietro Pavlica, MD. GVM-Care&Research, Villalba Hospital, Bologna, Italy

It is estimated that 10-20% of couples suffer from infertility and that male factor, by itself or in combination with female causes, is the reason for about 50% of couple-s infertility. Male infertility is actually divided in pretesticular infertility, testicular infertility and post-testicular infertility. Hormonal deficiency is the main reason of pretesticular failure and the role of imaging is limited to the detection of lesion localized in the hypothalamic-pituitary region where sometimes expansive lesions can be detected. Male infertility is most commonly due to a primary spermatogenesis defect (primary testicular failure). There is a wide spectrum of semen alterations that include at one end subfertile men with mild degree of spermatogenic impairment characterized by hypospermathogenesis and subnormal semen parameters (reduced sperm concentration, reduced motility and morphology changes). At the other end of the spectrum are men with endstage testicular failure characterized by azoospermia on semen analysis and complete germ cell aplasia or Sertoli cell only pattern on testicular histology. Varicocele is one of the major causes of testicular infertility in men, observed in 15-5% of the general male population. It is found in 41% infertile men and in 80% of those with secondary infertility. The pathogenetic mechanism through which varicocele causes testicular dysfunction is not completely understood. Various factors may be involved as venous stasis which leads to testicular hypoxia or the increasing of internal testicular temperature which is probably the most likely link between varicocele and infertility. Color/Doppler ultrasonography is the main method for diagnosis and allows the detection of the venous reflux in the spermatic veins. The examination must be performed in the erect position associated with the Valsalva maneuver. Other causes of testicular infertility are hemochromatosis, congenital adrenal hyperplasia and androgen insensitivity syndrome. In these cases the role of imaging is to assess the development of the genitalia using ultrasound, MR imaging and sometimes CT. Post-testicular infertility is clinically less frequent, but the role of imaging more important. Congenital abnormalities of the vas deferens, of the seminal vesicles and of the ejaculatory ducts are observed in patients with non- obstructive azoospermia. Vasal and/or epididymal obstruction may be congenital or acquired. Congenital abnormalities are well explored with MR imaging that shows vas agenesis, dysplasia of the seminal vesicles and cysts of the ejaculatory ducts. The precise definition of the site and extension of the obstruction can be definitely depicted with vasography. Inflammatory lesion of the epididymis and vas can be easily studied with sonography while inflammatory processes of the seminal vesicle and prostate explored with transrectal ultrasonography. With the explosion of knowledge and the new diagnostic techniques in uroradiology, it has become impossible to master it all, including the imaging examination of male patients with infertility. Who wants to be involved in male infertility needs to persue continuing education during practice lifetime and practice within larger groups facilities where an adequate volume of infertility cases are treated. Despite this situation the basic role of imaging in male infertility are part of general radiology training.

91 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY Scientific Sessions Scientific Session 1: Gynecological Tumors

SS1.01 - PROGNOSTIC VALUES OF PRETREATMENT SUVMAX AND ADCMEAN IN CERVICAL CANCER PATIENTS TREATED WITH DEFINITIVE CHEMORADIOTHERAPY Erbay G. 1, Onal C. 2, Reyhan M. 3, Guler O. 2, Koc Z. 1 Baskent University Faculty of Medicine Dept. of Radiology Adana-Turkey 1 Baskent University Faculty of Medicine Dept. of Radiation Oncology Adana-Turkey 2 Baskent University Faculty of Medicine Dept. of Nuclear Medicine Ankara-Turkey 3

Objective: The correlations between prognosis and pretreatment SUVmax and ADCmean of the primary tumor were determined in 63 patients with cervical cancer treated with definitive chemoradiotherapy.

Methods: Pre-teratment FDG-positron emission tomography (PET) and diffusion weighted magnetic resonance images (MRI) were taken for each patient. The correlation between SUVmax measured in PET and ADCmean measured in MRI was analyzed.

Results: There were significant correlations between SUVmax of the primary tumor and FIGO stage (p=0.04), tumor size (p<0.001), histology (p=0.04) and pelvic and/or para-aortic lymph node metastasis (p=0.005). The correlation between ADCmean and FIGO stage (p=0.001), tumor size (p<0.001), and lymph node metastasis (p<0.001) was significant. The SUVmax was significantly and inversely correlated with the ADCmin for cervical 2 cancer (R =−0.353, p<0.001). The relationship between primary tumor FDG uptake and ADCmean value and survival was evaluated by the cut-off value determined by receiver operating characteristic curve analysis.

The area under the curve for SUVmax and ADCmean were 0.851 (p<0.001; 95% CI, 0.755–0.953) and 0.727 (p=0.002; 95% CI, 0.595–0.859), respectively. 19.25 and 0.79 were determined as the SUVmax and ADCmean cut-off value. The disease-free and overall survival rates of patients exhibiting high SUVmax or low ADCmean of the primary tumor were significantly lower (p<0.001 and p=0.001).

Conclusion: High SUVmax and low ADCmean of the primary tumor is an important predictive factor for identifying patients with cervical cancer who have a poor prognosis.

SS1.02 - ADCMEAN IS A PREDICTIVE MARKER FOR METABOLIC RESPONSE IN CERVICAL CANCER PATIENTS TREATED WITH DEFINITIVE CHEMORADIOTHERAPY Erbay G. 1, Onal C. 2, Reyhan M. 3, Guler O. 2, Koc Z. 1 Baskent University Faculty of Medicine Department of Radiology Adana-Turkey 1 Baskent University Faculty of Medicine Department of Radiation Oncology Adana-Turkey 2 Baskent University Faculty of Medicine Department of Nuclear Medicine Ankara-Turkey 3

Objective: To investigate the correlation of the mean apparent diffusion coefficient value (ADCmean) on diffusion weighted imaging findings with treatment response detected with 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) cervical cancer patients treated with definitive chemoradiotherapy (ChRT).

Method: A cohort of 59 cervical cancer patients underwent pelvic magnetic resonance imaging (MRI) within the 2 to 4 weeks prior to definitive ChRT. Additionally all patient underwent PET before ChRT and after ChRT for assessing the metabolic response. Post-treatment PET-CT was delivered median 3.4 months (range 3.0 – 8.7 months) after completion of ChRT.

Results: The mean ± SD values of pretreatment ADCmean and SUVmax values were 0.89±0.18 and 18.91±8.86, respectively. Complete metabolic response (CMR) at post-treatment PET-CT was observed in 45 patients (76%), while 10 patients (17%) had partial response (PR) and 4 patients (7%) had progressive disease (PD). Mean ADCmean was significantly higher in patients with CMR compared to patients with PR or PD (0.93±0.17 vs. 0.76±0.14, p=0.001). The area under the curve for ADCmean was 0.841 (p<0.001; 95% CI, 0.727–0.956) and 0.87 was determined as the ADCmean cut-off value. The CMR were significantly higher in in patients with ADCmean≥0.87 (14 patients (31%) vs. 31 patients (69%); p<0.001). Likewise PR or PD rate was significantly higher in ADCmean<0.87 group (12 patients vs. 2 patients; p<0.001) compared to ADCmean≥0.87 group.

Conclusions: The ADCmean of primary cervical cancer calculated by MRI could be an important factor for treatment metabolic response with a risk of disease recurrence.

www.esur2013.org 92 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS1.03 - ADDED VALUE OF DIFFUSION-WEIGHTED MR IMAGING IN THE DIFFERENTIAL DIAGNOSIS OF BENIGN AND MALIGNANT SOLID COMPONENTS OF ADNEXAL LESIONS Rha S. 1, Oh S. 1, Byun J. 1 Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea Radiology Seoul-Korea, South 1

Objective: To investigate the added value of diffusion-weighted imaging (DWI) in the differential diagnosis of benign and malignant solid components in patients with mixed solid and cystic or predominantly solid adnexal masses.

Methods: Eighty-six patients with mixed solid and cystic or predominantly solid adnexal masses (61 malignant/borderline and 25 benign tumors) underwent MR imaging including DWI (b=0, 1000 sec/m2). Mature cystic teratomas and endometriomas were excluded from this study. We reviewed conventional MR images and the combined set of conventional MR images and DWI over a 4-week interval and determined benignity versus malignancy. Sensitivity, specificity, and accuracy of conventional MRI and combined set of MR images and DWI were calculated. For the quantitative analysis, the mean and the lowest apparent diffusion coefficient (ADC) of the solid components of ovarian masses were measured.

Results: The overall sensitivity was decreased from 98.3% to 96.6%, but the specificity increased from 42.3% to 61.5%. The accuracy of conventional MRI and combined DWI for characterizing malignancy was 81.4% and 86%, but there was no statistical difference. The ADC values (median; interquartile range, x 10-3 mm2/s) of the solid component of benign ovarian lesions (1.14; 0.92-1.64) was significantly higher than that malignant tumors (0.92; 0.82-1.13) (p=0.05), but there was a wide range of overlap of mean ADC values between benign and malignant tumors.

Conclusion: Although the addition of DWI has the potential to improve specificity for benignitiy, this did not reach statistical significance.

SS1.04 - UTERINE CERVICAL MALIGNANCY: DIAGNOSTIC ACCURACY OF MRI WITH HISTOPATHOLOGIC CORRELATION Koşar P. 1, Demir P. 1, Yiğit H. 1, Öztekin P. 1, Yurduseven E. 1, şimşek b. 1 Ankara hospital radiology Ankara-Turkey 1

The aim of our study was to evaluate the role of magnetic resonance imaging (MRI) in the staging of cervical malignancy in correlation with histopathologic examination. During the period between 11.2010 and 5.2013 consecutive 54 females with primary untreated pathologically proven uterine cervical carcinoma were included in this prospective study. Histopathologic diagnosis of the disease was established by means of pretreatment colposcopic biopsy and operation matherial. The patients were between 25 – 66 years of age. All patients were subjected to clinical staging workup and underwent MRI for preoperative staging. Preoperative MRI findings were reviewed and compared with the final pathological staging MR images were reviewed for the following characteristics of the cervical tumor: morphological characteristics, including origin, greatest diameters, margin ,tumor shape, signal intensity, growth pattern, and internal appearance, the presence of the tumor invasion into the parametrium, vagina, and adjacent organs and the presence of lymphadenopathy. Cervical cancer is staged by clinical examination according to the International Federation of Gynecology and Obstetrics staging system. We will argue the results of these study.

SS1.05 - PREDICTING THE TUMOR RESPONSE WITH DIFFUSION-WEIGHTED IMAGING IN CERVICAL CANCER PATIENTS TREATED WITH DEFINITIVE CHEMORADIOTHERAPY Erbay G. 1, Onal C. 2, Guler O. 2, Karadeli E. 1, Koc Z. 1 Baskent University Faculty of Medicine Department of Radiology Adana-Turkey 1 Baskent University Faculty of Medicine Department of Radiation Oncology Adana-Turkey 2

Objective: To investigate the ability of diffusion-weighted imaging (DWI) to predict the response of uterine cervical cancer treated with definitive chemoradiotherapy (ChRT) using apparent diffusion coefficients (ADCs).

93 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Materials: Forty-seven patients with median age of 57 years (ranged 21 – 86 years) with cervical cancer delivered conventional magnetic resonance imaging (MRI) and DWI prior to ChRT and after median 3.2 months (ranged 2.8 – 5.2 months) after therapy. Treatment response was assessed according to changes in tumor volume and ADC values measured in DWI’s taken before and after treatment. The response was was classified as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD).

Results: The mean tumor size was 5.4±1.6 cm (3.0 – 10.0 cm). Pretreatment and postreatment ADC values were 0.88±0.10×10−3/mm2/s and 1.14±0.17×10−3/mm2/s, respectively. Pretreatment and postreatment tumor volumes were 41.8±33.4 cc and 8.3±7.72 cc, respectively. Thirty-four patients (72%) had CR, 11 patients (24%) had PR and 2 patients (4%) had SD or PD. Pretreatment ADCs for CR were significantly higher than those of PR or PD (0.92±0.06×10−3/mm2/s vs. 0.77±0.08×10−3/mm2/s; p<0.001). Posttreatment ADCs were significantly higher in patients with CR compared to those with PR or PD (1.20±0.15×10−3/mm2/s vs. 0.97±0.07×10−3/mm2/s; p<0.001). Negative correlation was found between pretreatment ADCs and percentage size reduction after ChRT (R=0.57; p<0.001). However pretreatment volume and tumor size showed no statistically significant correlation.

Conclusion: ADCs may have the potential to be used to predict and monitor the response of uterine cervical cancer to therapy.

SS1.06 - REVIEW OF BORDERLINE OVARIAN TUMORS; IN KOREAN HOSPITAL Kim K. 1, Yoon S. 1 CHA Bundang Medical Center Radiology Sungnam-Korea, South 1

Purpose: We described the radiologic and histologic finding and character of borderline ovarian tumor (BOT) and followed up the post operative course.

Method : We retrospectively reviewed 110 BOTs in 106 patients. We analyzed epidemiologic data, radiologic finding-tumor size, solid mass extent, septal thickeness, numbers of cyst-and correlated with pathologic result. We followed up the post operative course including fetility, recurrence, disease free survival.

Result: There are 20 serous type and 90 nucinous type BOTs in 106 patients. there is no difference in age and size between serous and mucinous group. There is significant difference in isze of solid portion between serous and mucionous type BOTs and serous BOT showed larger solid portion than mucinous BOT. The thickeness of cyst were significantly thicker in mucionous BOT than serous one.

Conclusion: In Korea, mucinous type BOTs are predominent to serous BOTs. Serous BOT showed large solid portion just like serous adenocarcinoma. In mucinoous type BOT, thicker septum can be a chracteristic finding

www.esur2013.org 94 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 2: Prostate Cancer Imaging-I

SS2.01 - HIGH B-VALUE DIFFUSION WEIGHTED MR IMAGING AT 3 T FOR TUMOR DETECTION AND DISCRIMINATION OF AGGRESSIVENESS OF PROSTATE CANCER Tamada T. 1, Yamamoto A. 1, Jo Y. 2, Sone T. 1, Ito K. 1 Kawasaki Medical School Radiology Kurashiki-city-Japan 1 Kawasaki Medical School Urology Kurashiki-city- Japan 2

Objective: To investigate tumor conspicuity and the discrimination potential for tumor aggressiveness of prostate cancer on DW-MRI acquired with high b-value at 3 T.

Method: A total of 50 patients with prostate cancer (69 cancer foci) who underwent DW-MRI (b values: 0, 1000 s/mm2 and 0, 2000 s/mm2) on a 3 T system were included. As the DW-MRI assessments of prostate cancer, lesion conspicuity score (LCS) using visual assessment (four-point scale) and tumor-normal signal intensity ratio (TNR) were assessed, and apparent diffusion coefficient (ADC, ×10-3 mm2/s) of the tumor regions and normal regions were measured.

Results: Mean LCS and TNR of DW images at 0, 2000 s/mm2 was significantly higher than those at 0, 1000 s/mm2 (P <0.001 for both). Mean ADC of tumor regions in both 0, 1000 and 0, 2000 s/mm2 was significantly lower than those of normal regions (P <0.001 for both). In addition, ADC of tumor regions and Gleason score were significantly correlated at both 0, 1000 s/mm2 (ρ=-0.638; P <0.001) and 0, 2000 s/mm2 (ρ=-0.722; P <0.001), suggesting higher discrimination ability for tumor aggressiveness in ADC of 0, 2000 s/mm2, as compared with 0, 1000 s/mm2. Furthermore, in discriminating between insignificant cancers ≤GS6 and significant cancers ≥GS7, sensitivity and specificity were 84% and 83%, respectively, with an ADC cutoff level of 0.93.

Conclusion: For detection and characterization of prostate cancer on DWI of 3 T MRI, b = 0, 2000 s/mm2 is more useful than b = 0, 1000 s/mm2.

SS2.02 - EVALUATION OF DIFFUSION KURTOSIS IMAGING IN PATIENTS WITH PROSTATE CANCER Roethke M. 1, Kuru T. 2, Fenchel M. 1, Laun F. 3, Kuder T. 3, Hadaschik B. 4, Stieltjes B. 1 German Cancer Research Center (DKFZ) Radiology Heidelberg-Germany 1 Universityhospital Heidelberg Urology Heidelberg-Germany 2 German Cancer Research Center (DKFZ) Medical Physics Heidelberg- Germany 3 German Cancer Research Center (DKFZ) Urology Heidelberg-Germany 4

Objective: Diffusion-weighted imaging (DWI) is an essential functional modality in state-of-the-art multiparametric magnetic resonance imaging of the prostate. In clinical DWI, the apparent diffusion coefficient (ADC) is obtained using a monoexponential ADC fit. Additional microstructural information may be derived from diffusion kurtosis imaging (DKI) that describes the deviation of the diffusion propagator in tissue from a Gaussian function. Aim of the study was to investigate DKI in patients with prostate cancer (PCa).

Method:Twenty-three patients with biopsy proven peripheral PCa were included. All examinations were performed on a 3.0 Tesla scanner with combined body-phased coils. Data was acquired using a 2-D-EPI- sequence. Three orthogonal diffusion gradient directions were used with the following b-values: 0, 50,

250,500, 750, 1000, 1250, 1500, and 2000 s/mm². Parametric maps of Kapp (excess kurtosis) and Dapp (corrected diffusion coefficient) were calculated for each patient. For quantitative evaluation, regions of interests (ROI) were placed on the diffusion weighted image according to the histologically reported area of PCa and into the corresponding area on the opposite site on the same plane. Furthermore, a definite benign area was selected and measured in the same patient.

Results: Dapp was significantly lower and Kapp was significantly higher in cancerous versus both benign areas: -3 2 -3 2 -3 2 Dapp: 1.63 10 mm /s (±0.28 StD) vs 2.00 10 mm /s (±0.25) and 2.12 10 mm /s (±0.21); Kapp: 0.84 (±0.13) vs 0.65 (±0.09) and 0.61 10-3 mm2/s (±0.08).

Conclusion: DKI significantly differentiated between PCa and benign tissue and may improve sensitivity of DWI in patients with PCa.

95 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS2.03 - IDENTIFICATION OF APPARENT-DIFFUSION-COEFFICIENT (ADC) CUT-OFF-VALUES FOR THE DETECTION OF NODAL METASTASIS IN HIGH-RISK PROSTATE CANCER PATIENTS: IMPLICATION FOR CLINICAL PRACTICE Regier M. 1, Seiwerts C. 1, Henes F. 1, Isbarn H. 2, Adam G.1, Budaeus L. 2 University Medical Center Hamburg-Eppendorf Department of Diagnostic and Interventional Radiology Hamburg-Germany 1 University Medical Center Hamburg-Eppendorf Department of Urology Hamburg- Germany 2

Objective: The purpose of this study was to determine apparent-diffusion-coefficient (ADC) cut-off values for the differentiation of benign and malignant lymph nodes in patients suffering from prostate cancer in a high- risk constellation.

Method: In 59 consecutive D´Amico high-risk patients, pelvic MRI was performed prior to radical prostatectomy. A T2-STIR and DWI sequence were applied (b-values: 0, 25, 75, 100, 200, 500 and 900). ADC calculation was performed for all lymph nodes within the small pelvis. Overall, 1393 lymph nodes were removed, their location recorded and histopathologic analysis was performed. Finally, lymph nodes were dichotomized into benign and malignant and ADC cut-off values were determined using ROC, Wilcoxon and chi-square test.

Results: Histopathology revealed metastases in 35.6% (21/59) of all patients. All Lymph nodes >4mm were successfully identified at MRI. In malignant nodes the mean ADC was 0.76x10-3mm2/s, whereas in benign nodes the mean ADC was 1.43x10-3mm2/s (p<0.01). Furthermore, the minimum ADC was siginificantly lower in malignant (0.45x10-3mm2/s) than in benign (1.08x10-3mm2/s) nodes (p<0.01). ROC-analysis revealed a cut-off value of 0.98x10-3mm2/s (mean ADC) and 0.74x10-3mm2/s (minimum ADC) with an area under the curve (AUC) of >0.99 for the differentiation of benign and malignant nodes.

Conclusion: In a high-risk collective, DWI with ADC mapping can be used to assess lymph node metastases prior to prostatectomy. Mean and minimum ADC cut-off values of 0.98x10-3mm2/s and 0.74x10-3mm2/s allow for the discrimination of benign and malignant lymph nodes with high accuracy.

SS2.04 - EVALUATION OF THE PI-RADS CLASSIFICATION IN PATIENTS WITH NEGATIVE SYSTEMATIC PRE-BIOPSIES OF THE PROSTATE AND ONGOING CANCER SUSPICION Junker D. 1, Steinkohl F. 1, Bektic J. 2, Jaschke W. 1, Horninger W. 2, Aigner F. 1 Medical University Innsbruck Radiology Innsbruck-Austria 1 Medical University Innsbruck Urology Innsbruck- Austria 2

Objective:To evaluate multiparametric MRI (mpMRI) with PI-RADS classification for prostate cancer (PCa) detection in patients with negative systematic pre-biopsies and ongoing cancer suspicion.

Method:Within 1.5 years 139 men with mpMRI investigation at 3T (T2-weighted MRI, diffusion-weighted imaging and dynamic contrast-enhanced MRI) after negative systematic pre-biopsies were included. Risk stratification for each patient was done using the PI-RADS score: After scoring each modality separately (1- 5) an overall score was calculated. For PI-RADS 4 and 5 lesions MRI/ultrasound fusion guided re-biopsy, and for PI-RADS 3 lesions a follow up was recommended. The incidence of PCa within the PI-RADS categories was evaluated histopathologically for 67 patients with targeted re-biopsy and clinically for 12 patients with one year PSA follow up.

Results:Only 1 patient was scored with PI-RADS 1, 44 (31.8%) with PI-RADS 2, 48 (34.7%) with PI- RADS 3, 30 (21.8%) with PI-RADS 4 and 16 (11.7%) with PI-RADS 5. Five PI-RADS 2 patients underwent systematic re-biopsy and were tumor negative, 11 showed decreasing, 1 rising PSA levels (<5% PCa incidence). With targeted re-biopsy PCa was found in 2 of 17 patients with PIRADS 3 (12%), 19 of 29 with PI-RADS 4 (66%) and in 15 of 16 with PI-RADS 5 (94%). Benign PI-RADS 3-5 lesions were inner gland adenomas or inflammations. Overall 36 (26%) clinically significant tumors (>0.5 cm³ or gleason >6) were found. Of these 58% were anterior and 45% inner gland tumors. Conclusion:MpMRI using PI-RADS score is a helpful and reliable tool for risk stratification in this challenging patient collective.

www.esur2013.org 96 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS2.05 - RISK STRATIFICATION OF POSSIBLE PROSTATE CANCER USING PREBIOPSY MRI: A MULTISITE STUDY Picker W. 1, Grønning L. 1, Christiansen E. 2, Karlsen K. 3, Kvan E. 4, Kristoffersen K. 5, Molven S. 4, Brennhovd B. 4, Moen J. 4, Willoch F. 1 Aleris Health Cancer Center Oslo-Norway 1 Urologisk Senter Oslo-Norway 2 Curamedica Sarpsborg-Norway 3 Aleris Health Oslo-Norway 4 Volvat Fredrikstad-Norway 5

Objective: The presented study evaluates the diagnostic performance of diffusion weighted (DW) MRI of the prostate in a specialized Prostate MRI unit serving 4 referring urological sites performing both target guided and general TRUSBx.

Method: 234 patients underwent T2 and Diffusion (DW) MRI of the prostate MRI prior to TRUSBx. Suspect MRI lesions were scored in 3 categories: Probably benign (1), probably malignant (2) and highly suspicious for malignancy (3), using diagnostic criteria according to PI-RADS. The highest Gleason Grade (HGG) in the histology report was compared to the highest MR score (HMRS).

Results: There was a different prevalence of HMRS scores between the referring sites. Site 1, which performed MR in all its prostate patients, had an even distribution of HMRS scores: grade 1(32%), grade 2 (36%), grade 3 (35%). There was a positive correlation between increasing MRS both with increasing numbers positive biopsies and increasing maximum Gleason score. All sites had similar results in patients with probably benign MR findings, but site 1 found more cancers in total (44% in HMRS 4 and 87% in HMRS 3) and more prevalent high grade disease (17% Gleason >7B in HMRS 2 and 44 % Gleason >7B in HMRS 3).

Conclusion: High quality DW MRI is a good predictor for the outcome of consecutive TRUSBx biopsy. The cancer detection rate of standard TRUSBx after MRI is user dependent. HMRS 1 is a good predictor of absent and HMRS 3 of present significant PCa.

SS2.06 - PREOPERATIVE MRI PROSTATE FOR DIAGNOSIS OF T3 PROSTATE CANCER: MRI WITH PATHOLOGICAL CORRELATION. Lyall H. 1, Bretsztajn L. 1, Smith J. 2 Leeds General Infirmary Radiology Leeds-United Kingdom 1 Leeds St James Hospital Radiology Leeds- United Kingdom 2

Objective: To correlate the preoperative MRI staging of the prostate with the post-operative pathological findings to assess the sensitivity/specificity of MRI in detecting non-organ confined (T3) Prostate Cancer.

Method: MRI and histopathology reports were correlated for 45 patients who had undergone robotic prostatectomy for prostate cancer in Leeds Teaching Hospitals in 2011. We compared the preoperative MRI with pathological findings post-prostatectomy and determined the sensitivity/specificity in the diagnosis of non-organ confined (T3) Prostate cancer.

Results: Preoperative MRI prostate was compared with pathological findings in 45 patients undergoing robotic prostatectomy. The sensitivity of preoperative MRI staging was 31%, Specificity was 89%.

Conclusion: The study demonstrates MRI is specific but not sensitive in the diagnosis of non-organ confined (T3) Prostate cancer. This corresponds to results from previous studies.

97 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 3: Renal Tumors

SS3.01 - ROLE OF DIFFUSION WEIGHTED SEQUENCE AND APPARENT DIFFUSION COEFFICIENT IN CHARACTERIZATION OF RENAL MASSES IN PATIENTS WITH MEDICAL NEPHROPATHY. Afifi -hafez a. 1, Ramadan -aly a. 1, Nafess-mahmoud s. 2, Mehanna -mohmad a. 1, Badawy-mohmad h. 1 Faculty of Medicine Radiology Alexandria-Egypt 1 faculty of medicine urology alexandria-Egypt 2

Objectives : When an indeterminate renal lesion is detected by ultra sound in patients with medical nephropathy, further assessment by contrast enhanced computed tomography (CT) is prohibited and only limited data can by obtained by non contrast CT regarding . Our objectives was to assess the role of non contrast enhanced MRI with diffusion weighted sequence as a sole imaging method in characterization of renal masses in patients with medical nephropathy.

Methods: 18 patients with medical nephropathy and indeterminate renal lesions (22 lesions ) detected by ultra sound and non contrast CT and prospectively studied as well as and 10 incidentally discovered simple renal cysts in the study population . The examinations were done on 1.5T machines using by conventional non contrast MRI sequences including diffusion weighted sequence.

Results: MRI was able to differentiate neoplastic lesions from cystic lesions in all cases, fluid and blood signal were readily identified by T1 and T2 weighted sequence while solid lesions showed T2 hypo-intensity or T2 heterogenicity due to associated necrosis. In diffusion weighted sequence simple and septated cysts showed no restriction with high Apparent diffusion coefficient (ADC) value, malignant lesions showed restricted diffusion while hemorrhagic cysts showed variable appearance on diffusion.

Conclusion: Our results suggest that non contrast MRI with diffusion-weighted sequence gives important data regarding differentiation of neoplastic lesions and cystic

SS3.02 - DIFFERENTIATION BETWEEN RENAL CELL CARCINOMA SUBTYPES USING DIFFUSION WEIGHTED SEQUENCE Afifi -hafez a. 1, Ramadan -aly a. 1, Nafess-mahmoud s. 2, Mehanna -mohmad a. 1, Hesham b. 1 Faculty of Medicine Radiology Alexandria-Egypt 1 faculty of medicine urology alexandria-Egypt 2

Objectives: The classification of renal cell carcinoma into subtypes has become of interest because of the association with prognosis. Recent developments in the understanding of the biology of renal cell carcinoma (RCC) have substantial therapeutic implications. The identification of tyrosine kinase inhibitors (eg, sunitinib, sorafenib) as effective treatment options for patients with clear cell RCC but with less efficacy for patients with papillary and chromophobe tumors , as well as the enhanced benefit of temsirolimus for the treatment of patients with papillary tumors, are exemplary of the importance of a targeted approach to treatment for RCC tumors.

To assess the role of diffusion weighted sequence in differentiating renal cell carcinoma subtypes.

Methods: 33 patients with 37 renal cell carcinomas detected by ultra sound and multislice CT were prospectively studied. The examinations were done on 1.5T machines using conventional MRI sequences and diffusion weighted sequence. Assesment of ADC value and ADC ratio between the tumor and the normal parenchyma was made

Results: Diffusion weighted sequence was able to differentiate between CRCC from other RCC subtypes where the former showed higher ADC value (1.1±0.2 ranging from 0.6±1.4x 10-3 mm2/s versus 0.7±0.1 ranging from0.5-0.8x 10-3 mm2/s) and T/P ratio ( 0.56±0.11versus0.4±0.05) with P<0.0001.

Conclusion: Our results suggest that differentiation between renal cell carcinoma subtypes is possible using diffusion weighted sequence.

www.esur2013.org 98 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS3.04 - UTILITY OF MR IMAGING FOR PREDICTION OF NUCLEAR GRADE IN CLEAR CELL RENAL CELL CARCINOMA Yamamoto A. 1, Tamada T. 1, Ito K. 1, Kanki A. 1 Kawasaki Medical School Radiology Kurashiki-Japan 1

Purpose: The purpose of this study was to assess the magnetic resonance (MR) imaging findings for prediction of nuclear grade in clear cell renal cell carcinoma (ccRCC).

Materials and Methods: This study included a total of 34 renal masses with pathologically proven ccRCC with Fuhrman grade 1 (n=3), grade 2 (n=14), grade 3 (n=13), grade 4 (n=4) in 34 patients who underwent MR imaging including dynamic contrast-enhanced (DCE) imaging diffusion-weighted (DW) imaging and T2- weighted imaging prior to operation. The contrast enhancement ratio {CER = (SI post - SI pre) / SI pre} in each phase, the apparent diffusion coefficients (ADCs), the signal-to-muscle ratios (SMRs) of T2-weighted imaging and tumor size were evaluated the relationship between Fuhrman grade and compared between low and high nuclear groups.

Results: A significant negative correlation was identified between ADC and Fuhrman garde There was a significant difference in CER of corticomedullary phase between clear cell and non-clear cell RCC (260% vs. 40%; P < 0.001). The difference was also significant in ADC between clear cell and non- clear cell RCC (1.8 x 10-3 mm2 / sec vs. 1.2 x 10-3 mm2 / sec; P = 0.02). In the comparison of diagnostic performance between DCE MR imaging and DW MR imaging, area under the curve (AUC) to distinguish clear cell and non-clear cell RCC were 0.96 in CER of CP and 0.81 in ADC.

Conclusion: CER of corticomedullary phase was more reliable than ADC to distinguish clear cell and non- clear cell RCC.

SS3.05 - DIFFERENTIATION OF BENIGN AND MALIGNANT RENAL LESIONS WITH INTERFACE TYPES AT MRI Kulali F. 1, Kulali S. 2, Semiz-Oysu A. 1, Bukte Y. 1, Kaya-Tuna B. 1 Umraniye Training and Research Hospital Department of Radiology Istanbul-Turkey 1 Umraniye Training and Research Hospital Department of Urology Istanbul-Turkey 2

Objective: To investigate renal interface types of exophytic renal masses at magnetic resonance imaging (MRI) for differantiation of benign and malignant lesions.

Method: The institutional review board approved the study protocol. Preoperative MRI of 47 patients with exophytic renal masses who underwent nephrectomy and MRI of 53 patients with Bosniak category I or II exophytic renal cysts without progression at follow-up were retrospectively reviewed. A single radiologist evaluated MRI without knowing histopathological results, and recorded renal interface types as angular or round at T2 weighted axial sequences. The size and locations of tumors were also noted. The relationship between histopathological results and renal interface types of renal masses was statistically compared.

Results: Of 100 masses, 62 were benign and 38 were malignant. 49 of masses which had angular interface with renal parenchyma were all benign lesions (Bosniak category I or II cysts). 51 masses had round interface (13 benign, 38 malignant). There was a statistically significant difference between renal interface types of benign and malignant lesions (p<0,01) and also tumor size (p<0,01). All renal lesions with angular interface were benign. Malignant tumors had larger size compared to benign lesions (5,30±3,08 cm and 3,52±,96 cm respectively). Tumor locations showed no significant difference between benign and malignant lesions.

Conclusion: Angular interface of renal masses at MRI can be a predictor of benignity. Especially when gadolinium enhanced imaging is not available, T2 weighted axial MRI can be helpful. Although most of the lesions with round interface are malignant, some benign lesions may show round interface also.

99 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS3.06 - COMPUTED TOMOGRAPHY IN THE DIAGNOSIS OF KIDNEY MALIGNANT LYMPHOMA Titorenko R. 1 Diagnostic center MEDISCAN Donetsk-Ukraine 1

Purpose: To identify main criteria of the CT-semiotics and differential diagnosis of renal lymphoma.

Materials And Metods: We have examined 553 patients with various forms of lymphoma which were treated in the chemotherapy unit of City Hospital № 2 in Makeyevka, Ukraine. In the baseline, and follow-up patients’ examination plan were included CT neck, chest, abdomen, retroperitoneum, pelvis with nonionic contrast bolus.

Results: The extranodal lesions were identified in 45% of case. Renal involvement was found in 58 (10.5%) patients, 13 were HIV-infected. Of these, the solitary lesion was detected in 3 (5.2%) patients, multifocal lesion was noted in 27 (46.3%) cases, direct extension from retroperitoneal adenopathy - 15 (26%) cases, diffuse infiltration - 7 (12.3 %) cases. Defeat pararenal space was observed in 6 (10.2%) patients. Conclusions: The urinary tract is a common site for extranodal spread of lymphoma, particularly non-Hodgkin lymphoma. CT with bolus contrast remains the basic method of kidneys lymphoid lesions’ diagnosis, which allows to specify the nature and extent of the lymphoid process.

SS3.07 - RADIOLOGICAL FEATURES OF UNUSUAL RENAL MASSES Cheikh Ahmad I. 1, Atay M. 1, Sonmez F. 2, Armagan A. 3, Kocakoç E. 1 Bezmialem Vakıf Universty Radiology İstanbul-Turkey 1 Bezmialem Vakıf Universty Pathology İstanbul-Turkey 2 Bezmialem Vakıf Universty Urology İstanbul-Turkey 3

Aim: To discuss the radiological features of unusual renal lesions

Materials and Methods:One hundred twenty three cases referred to our hospital in the last 2.5 years were enrolled in this study. Dynamic contrast-enhanced CT or MRI was performed for radiological diagnostic method. Both radiological and histopathological diagnoses were available in 88 cases. 35 cases with radiological diagnosis of angiomyolipoma did not undergo histopathological examination.

Results:On pathological examination, 54 of 88 cases were renal cell carcinoma ( 33 clear cell type, 8 papillary variant, 7 chromophobe cell type, 3 multiloculated cystic carcinoma, 1 tubulopapillary type, 1 tubulocystic type, 1 clear cell type with sarcomatoid areas), 12 cases were transitional cell carcinoma, 5 cases were inflammatory lesions, 3 cases were Wilm’s tumor, 2 cases were oncocytoma, 2 cases were squamous cell carcinoma , 2 cases were renal textiloma, 2 cases were inflammatory pseudotumor, 1 case renal liposarcoma, 1 case was diffuse large B-cell lymphoma, 1 case was hydatid cyst, 1 case was metanephric adenoma, 1 case was metastasis of rectal adenocarcinoma and 1 case was angiomyolipoma.

Conclusion:The unusual radiological features of small number cases were presented. Clear cell and papillary RCC can be diagnosed usually preoperatively. If unusual imaging appearances were present pathological results were also unusual.

SS3.08 - SUBTYPE DISCRIMINATION OF RENAL CELL CANCER BY USING DIFFUSION IMAGES Çolakoğlu Er H. 1, Peker E. 1, Öztürk E. 2, Erden A. 1 Ankara University Radiology Ankara-Turkey 1 Ankara University Urology Ankara-Turkey 2

Our purpose was to determine whether quantitative diffusion weighted magnetic resonance imaging (DWI) could be used to discriminate papiller type renal cell cancer (PC) and clear cell type renal cell cancer (CCC). A total of 13 patients with PC or CCC were enrolled in this retrospective study. DWI was performed at 3 Tesla unit. Mean diffusion and apparent diffusion coefficient (ADC) values at b50, 400 and 1000 signal intensities of normal kidney and solid components of the renal masess were calculated. Freehand region of interest (ROI) was defined for the lesions detected on the DWI, while referring to the T2-weighted conventional sequence for verification of lesion boundaries. To measure diffusion value and ADC value of normal renal parenchyma, ROI’s were placed in the normal corticomedullary junction. Statistical significant difference (p<0,01) in ADC values between two groups were found. ADC values of PC (mean: 1029,1 and median: 1056,6) was lower than the CCC (mean: 1374,6 and median: 1384,5). For the PC group, there was statistically significant difference (p<0,05) in b1000 values (mean: 43,1 and median: 51,1 for lesion and mean: 24 and median: 24,4 for normal parenchyma) and for the CCC group there was statistically significant difference (p<0,05) in b50 values (mean: 102,5 and median: 106,6 for lesion and mean: 140,9 and median: 131 for normal parenchyma) between normal parenchyma and lesion, which allowed us to discriminate the lesion borders easily on b1000 values and on b50 values respectively for PC and CCC.

www.esur2013.org 100 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 4: Interventional Procedures & Minimally Intasive Therapies

SS4.01 - FLUOROSCOPICALLY GUIDED REMOVAL OF ‘LOST THREAD’ IUCDS: A NOVEL TECHNIQUE Harvey H. 1

Brighton & Sussex University Hospitals Trust Interventional Radiology Brighton-United Kingdom 1

Lost or retracted strings are a common problem for women with IUDs which are due to be replaced or removed. A new technique has been developed to replace the current gold standard hysteroscopic removal.

A novel transcervical technique using a standard intravascular Tulip snare and catheter under fluroscopic guidance in the interventional suite was performed on over 150 patients, without need for day surgery, oral or local anesthesia.

The technique, equipment, dosages and outcomes are presented.

SS4.02 - ULTRASOUND GUIDED UROGENITAL INTERVENTIONS: PROCEDURAL TECHNIQUES AND CLINICAL USEFULNESS Pugh J. 1, Clark A. 1, George C. 1 University Hospital of North Staffordshire Imaging Stoke-on-Trent-United Kingdom 1

Ultrasound is an easily available, relatively cheap, but operative dependent imaging modality that has many uses in interventional radiology. It plays an important role in many uro-genital procedures such as biopsies, aspirations, and drainages. This presentation describes and demonstrates procedural techniques and the clinical usefulness of ultrasound in uro-genital image-guided interventions and how it helps in patient management.

SS4.03 - PYONEPHROSIS - AN OVERDIAGNOSED CONDITION? Gregertsen K. 1, Lönnemark M. 1, Heinius J. 2 Faculty of medicine, Uppsala University Department of radiology, university hospital, Akademiska sjukhuset Karlstad-Sweden 1 Faculty of medicine, Uppsala university Department of urology, university hospital, Akademiska sjukhuset Uppsala-Sweden 2

Introduction: Pyonephrosis is a lifethreatening condition, a complication of urolithiasis often associated with gram-negative sepsis. Pyonephrosis is defined as pus in the obstructed collecting system of the kidney. Infection in the obstructed collecting system ranges between pyonephrosis and infected hydronephrosis. E coli and other gramnegatives, are the most common in pyonephrosis just as in other forms of urinary tract infections. The established treatment of pyonephrosis/infected hydronephrosis is intravenous broad spectrum antibiotics combined with either retrograde insertion of a ureteral stent or percutaneous nephrostomy. However, there has been a suspicion that there has been an over-diagnosis of pyonephrosis and nephrostomies have been performed on wrong indications.

The aim of this study was to determine whether patients with suspected pyonephrosis were treated with percutaneous nephrostomy, out of office hours, on correct indications.

Method: This was a retrospective study. Records of patients who were treated with percutaneous nephrostomy because of suspected pyonephrosis were reviewed and parameters concerning the clinical and radiological presentation were extracted.

Results: In 17 of the patients there was a computer tomography preceding the percutaneous nephrostomy. In 84 % of these there were at least 2 signs of obstruction. In 16 patients the diagnosis pyonephrosis was confirmed when purulent or cloudy urine was drained from the percutaneuos nephrostomy. The remaining 9 cases were reviewed by an experienced urologist and in only one case the diagnosis infected hydronephrosis could not be confirmed.

Conclusion: The conclusion was that a majority of the patients (24/25) received a percutaneous nephrostomy on correct indications.

101 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS4.04 - RADIOFREQUENCY ABLATION (RFA) OF RENAL CELL CARCINOMA (RCC): EXPERIENCE IN 200 TUMOURS Wah T. 1, Mohammed A. 1 , Irving H. 1, Gregory W. 2, Cartledge J. 3, Joyce A. 3, Selby P. 4 Institute of Oncology, St. James’s University Hospital, Leeds Teaching Hospitals Trust Diagnostic and Interventional Radiology Leeds-United Kingdom 1 University of Leeds Clinical Trials Research Unit (CTRU) Leeds-United Kingdom 2 Institute of Oncology, St. James’s University Hospital, Leeds Teaching Hospitals Trust Department of Urology Leeds-United Kingdom 3 St. James’s University Hospital Leeds Institute of Molecular Medicine Leeds-United Kingdom 4

Purpose: To report our clinical experience with percutaneous image-guided RFA of 200 renal tumours in a large university institution

Materials and Methods:Image-guided RFA of 200 renal tumours in 165 patients was prospectively evaluated. Cold pyeloperfusion/hydrodissection technique was used accordingly to protect the ureter or surrounding vital structures and all renal tumours were biopsied at the time of the RFA treatment. The treatment response and technical success were defined by absence of contrast enhancement within the tumour on contrast enhanced CT/MRI. Both major and minor complications, the management and outcomes of the complications as well as oncologic outcome were prospectively documented. Multivariate analysis was performed to determine variables associated with technical success and major complications. The overall, 5-year cancer specific, local recurrence-free and metastasis-free survival rates are presented using the Kaplan Meier Curves.

Results: 200 tumours were treated RFA with size ranging from 1-5.6cm (mean=2.9cm) and age range 21- 88.6 years (mean= 67.7). Amongst them, 197 (98.5%) were completely ablated (191 in a single ablation session, 3 after a second ablation session and 3 after a third session) with a mean follow-up period of 46.1 months. Three patients declined re-treatment. Major complications: ureteric injury (n=6), calyceal-cutaneous fistula (n=1), acute tubular necrosis (n=1) and abscess formation (n=2). The overall, 5-year cancer specific, local recurrence-free and metastasis-free survival rates are: 75.8%, 97.9%, 93.5% and 87.7% respectively

Conclusions: Image-guided RFA is a safe, nephron sparing and effective treatment for small RCC tumours with a low rate of recurrence and has good 5-year cancer specific and metastasis free survival rates.

SS4.05 - THE MID TERM OUTCOME OF IMAGE GUIDED PERCUTANEOUS CRYOABLATION (CRYO) OF RENAL TUMOURS Wah T. 1, Jagirdar N1., Gregory W. 2, Smith J. 1, Cartledge J. 3, Joyce A. 3, Selby P. 4 Institute of Oncology, St. James’s University Hospital, Leeds Teaching Hospitals Trust Diagnostic and Interventional Radiology Leeds-United Kingdom 1 University of Leeds Clinical Trials Research Unit (CTRU) Leeds-United Kingdom 2 Institute of Oncology, St. James’s University Hospital, Leeds Teaching Hospitals Trust Department of Urology Leeds-United Kingdom 3 St. James’s University Hospital Leeds Institute of Molecular Medicine Leeds-United Kingdom 4

Purpose: To present our mid-term experience of CT-guided CRYO of RCC at a single university institution

Materials and Methods:CT-guided CRYO under general anaesthesia was performed on 90 renal tumours in 81 patients from 2008 to 2013. Warm pyeloperfusion, pneumo-/ hydro-dissection technique was used accordingly. Prospective documentation of the patients’ demographic, renal function, treatment details and outcomes were reviewed.

Results: Ninety renal tumours with a mean size of 2.9cm in 81 patients were treated and 84 (93%) renal tumours were biopsied proven RCCs. The age range 21.6 to 86.5 years with mean follow up period 26.3 months. The primary and overall technical success rates: 94.4% vs. 98.9% respectively. All residual disease requiring repeated treatment (n=5) occurred when performed by operators with <12 months of experience. One patient declined re-treatment. There is a significant difference between the pre- and post-CRYO GFR with a mean difference of 2.4 with the pre-GFR is higher before treatment (p <0.03). Seven patients developed >25% decreased in GFR and 91% of the patients had preservation of renal function. Our minor and major complication rates were 5.3% and 1.1% respectively. One predicted ureteric injury occurred while treating a centrally located renal tumour adjacent to the renal pelvis without warm pyeloperfusion during our initial experience. At our mid-term follow up, we have no local disease progression or distant metastasis progression.

Conclusions: CT-guided CRYO of renal tumours is a safe technique that offers preservation of renal function in majority of the patients and has good mid-term treatment outcomes.

www.esur2013.org 102 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS4.06 - RENAL CRYOABLATION: DOES TUMOUR POSITION EFFECT TECHNICAL AND ONCOLOGICAL OUTCOME? King A. 1, Ingram L. 1, George S. 2, Breen D. 1 University Hospital Southampton Department of Radiology Southampton-United Kingdom 1 University Hospital Southammpton Primary care and Population sciences Southampton-United Kingdom 2

Objective: To assess the influence of renal tumour position on both the technical and oncological success of renal cryoablation.

Method: We performed a retrospective analysis of our renal cryoablation database. The cohort was subdivided by tumour position (anterior or posterior) and analysed in terms of technical success (subtotal treatment or procedural complication) and oncological outcome (late local recurrence). All tumours were treated with curative intent by cryoablation and followed up with contrast enhanced CT or MRI.

Results: Of 208 tumours, 90 were anterior, 118 were posterior, and 122 were proven histologically to be malignant. 11 subtotal treatments occurred, with only 9 complications (Clavien-Dindo Grade Grade II or more) recognised from 188 procedures (4.8% complication rate). A mean follow up period of 17 months (range 1-58) revealed 4 late local recurrences, all of which have been retreated. Subgroup logistic regression analysis demonstrated no significant influences in technical success, complication rate, or local recurrence based on anterior tumour position. An increased risk of complication associated with upper pole tumours (p=0.036) is probably due to small pneumothoraces not requiring medical intervention.

Conclusion: Evaluation of our database has proven that there is no statistically significant increased risk in cryoablating anteriorly located tumours. In our experience, subtotal treatment and procedural complications are far more likely to occur early in the learning curve.

SS4.07 - IMAGE-GUIDED THERMAL ABLATION OF ADRENAL TUMOURS – A SINGLE CENTRE EXPERIENCE King A. 1, Abbas A. 1, Idriz S. 2, McGill N. 3, Breen D. 1 University Hospital Southampton Department of Radiology Southampton-United Kingdom 1 St Georges Hospital Department of Radiology London-United Kingdom 2 University Hospital Southampton Department of Anaesthetics Southampton-United Kingdom 3

Objective: Thermal ablation is becoming widely accepted a highly effective treatment option for many visceral tumours. The comparatively low prevalence of clinically significant adrenal tumours that require treatment means that worldwide experience of adrenal ablation is relatively small. We present our experience of 8 cases over 5 years.

Method: 8 tumours (7 Conn’s adenomas and 1 renal metastasis) were treated in our institution with thermal ablation (7 Cryoablation, and 1 RFA) between May 2008 and May 2013. All cases were treated under general anaesthetic by a single operator using CT guidance. Tumour size ranged from 14mm to 25mm with an average of 17mm. 4 tumours were left-sided.

Results: There were no technical complications, but 5/8 patients experienced hypertensive episodes during the ablation. All patients were discharged within 48hours. One subtotal treatment has been recorded after unsuccessful targeting due to unexpected tumour depth. 6 patients have completed adequate radiological, biochemical and physiological follow-up to permit accurate treatment analysis. A complete response has been seen in 3/5 Conn’s patients and a partial response in 1. The metastatic lesion was successfully ablated and there is only one confirmed treatment failure.

Conclusion: In our initial experience, thermal ablation of adrenal tumours appears to offer a technically feasible procedure which confers minimal risk to the patient. If our results in Conn’s tumours could be reproduced in a larger population, the therapeutic response rates would be comparable to the riskier surgical techniques and result in fewer procedural complications.

103 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS4.08 - THE EFFECT ON RENAL FUNCTION FOLLOWING IMAGE GUIDED RADIOFREQUENCY ABLATION (RFA) OF RENAL TUMOURS Wah T. 1, Mohammed A. 1 ,Gregory W. 2, Irving H. 1, Cartledge J. 3, Selby P. 4 Institute of Oncology, St. James’s University Hospital Diagnostic and Interventional Radiology Leeds-United Kingdom 1 University of Leeds Clinical Trials Research Unit (CTRU) Leeds-United Kingdom 2 Institute of Oncology, St. James’s University Hospital Department of Urology Leeds-United Kingdom 3 St. James’s University Hospital Leeds Institute of Molecular Medicine Leeds-United Kingdom 4

Aims: To analyse changes in GFR in patients who had image-guided RFA of their renal tumours and to correlate the percentage GFR change (% GFR change) with tumour size, polar position, tumour treatment location, the total size of the tumour treated per ablation session, number of tumours treated and solitary kidney status.

Methods: A total of 165 patients (109 men, 56 women; mean age 67.7 years) had RFA of 200 renal tumours with size ranging from 1-5.6cm (mean= 2.9cm). The position of the renal tumours was: upper (n=63), middle (n=86) and lower (n=51). The tumour location was: exophytic (n=43), mixed (n=100), parenchymal (n=41) and central (n=16). All patients had renal function measured immediately before and at 24 hours post- RFA. Multivariate logistic regression analysis was performed to determine any association between % GFR changes with the tumour/ solitary kidney factors.

Results: The mean GFR pre- and post-RFA were: 54.7 (+/- SD 18.2) vs. 52.7 (+/- SD 18.5) ml/min/1.73m2, which is statistically significant (p <0.0001), with a mean reduction in GFR of 2.03 ml/min/1.73m2 post-RFA. Four patients developed >25% decreased in GFR whilst 98% of the patients renal function was preserved. The mean % change of GFR pre- and post-RFA was – 3.1%. However, using multivariate logistic regression analysis there was no association between the % of GFR change with any of the tumour/ solitary kidney factors.

Conclusion: Preservation of the renal function can be achieved following image-guided renal RFA and the percentage of GFR change was not influenced by tumour factors or solitary kidney status.

www.esur2013.org 104 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 5: Fetal Imaging

SS5.01 - FETAL BIOMETRY IN POLYHYDRAMNIOS: DOES FEMUR LENGTH FALL BEHIND? Ipek A. 1, Idilman I. 1, Kurt A. 2, Cay N. 1, Unal O. 1, Doganay Erdogan B. 3, Keskin H. 4, Arslan H. 1 Ankara Atatürk Education and Research Hospital Radiology Ankara-Turkey 1 Dıskapı Yildirim Beyazit Education and Research Hospital Radiology Ankara-Turkey 2 Ankara University School of Medicine Biostatistics Ankara-Turkey 3 Ankara Atatürk Education and Research Hospital Obstetrics and Gynecology Ankara-Turkey 4

Objective: We aimed to identify the growth patterns in polyhydramnios and compare this pattern in overgrowth and non-overgrowth fetuses to identify additional factors stimulating overgrowth in polyhydramnios and predict macrosomia in utero.

Method: In this retrospective study, we searched the medical records of obstetric ultrasound screening from January 2007 to January 2013 for singleton pregnancies with polyhydramnios who have both second and third trimester screening. In these 108 pregnancies, growth patterns of fetuses according to third trimester relative to second trimester were evaluated and maternal, pregnancy characteristics and pregnancy outcomes in overgrowth and non-overgrowth fetuses were compared.

Results: In the study population BPD and AC percentiles had a significant increase (p= 0.023 and 0.05, respectively) despite FL percentiles had a significant decrease (p= 0.006). In overgrowth group (n= 52), maternal parity was higher (p= 0.037) and FL/BPD ratio was lower (p< 0.001) with more fetuses with FL/BPD ratio below 71 (p= 0.05). In overgrowth group, macrosomia incidence (p= 0.004) and birth weights (p= 0.012) were higher.

Conclusion: There is a significant increase in BPD and AC percentiles and decrease in FL percentiles in third trimester relative to second trimester in fetuses with polyhydramnios. We can encounter a shorter FL and lower FL/BPD ratio especially in overgrowth fetuses in third trimester with no associated skeletal dysplasia in polyhydramnios. By classifying fetuses according to changes in the follow up, the risk for macrosomia can be anticipated.

SS5.02 - CAVUM SEPTUM PELLUCIDUM ET VERGAE FREQUENCY IN NORMAL FETUSUS IN THIRD TRIMESTER Unal O. 1, Ipek A. 1, Idilman I. 1, Cay N. 1, Keskin H. 2, Arslan H. 1 Ankara Ataturk Research and Radiology Radiology Ankara-Turkey 1 Ankara Ataturk Research and Radiology Obstetric and Gynecology Ankara-Turkey 2

Objective : We aimed to measure the thickness and volume of cavum vergae in the fetuses between gestational ages 25-41 with ultrasound; to identify the relationship of the thickness and volume of cavum vergae with the gestational age and BPD; and to calculate the closure rate of cavum vergae per gestational weeks.

Method: Between February and July 2010, 336 cases aged 17-41 and having third trimester gestations, were evaluated through transabdominal approach. In these cases, fetal cavum vergae was defined and measured. CV was defined on the axial and coronal plan and the largest internal surface on the axial plan was measured by marking inwardly. Detailed analyses of fetuses were done in terms of any related anomaly.

Results: In 55 out of 322 cases (17%) CV volume and thickness could not be calculated because the CV was closed. In the remaining cases, CV volume thickness and BPD were measured. While the degree of correlation between cavum vergae thickness and volume increased with the increasing gestational week, there is no correlation seen between cavum vergae thickness and volume on the gestational weeks 37- 41. Besides, no meaningful correlation between BPD and thickness and volume was identified while the gestational week increased.

Conclusion: There was no statistically meaningful change in the cavum vergae thickness and volume of the cases within the study, as the gestational week proceeded. Also, CV closure rate increases on a statistically meaningful level as the gestational week increases.

105 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS5.03 - FETAL MAGNETIC RESONANCE IMAGING OF GENITOURINARY PATHOLOGIES Özkul B. 1, Anık Y. 1, Yücesoy G. 2, Bek K. 3, Anık İlhan G. 4, Demirci A. 1 Kocaeli university medical school Radiology Kocaeli-Turkey 1 Kocaeli university medical school Gynecology and obstetrics Kocaeli-Turkey 2 Kocaeli university medical school Pediatrics Kocaeli-Turkey 3 Dr. Lütfi Kırdar Kartal education and research hospital Gynecology and obstetrics İstanbul-Turkey 4

Objective: To evaluate the role of fetal magnetic resonance imaging in the diagnosis of genitourinary pathologies.

Method: Genitourinary pathologies of 83 fetus were evaluated. Patients were initially evaluated by ultrasonography. Fetal magnetic resonance imaging was performed for accompanying pathologies, patient management and assessment of the anomaly in detail for planning required surgical procedures. All patients were scanned via 1.5T magnetic resonance equipment with synergy coil in supine position. Single shot T2 weighted images were obtained in three planes. Genitourinary pathologies were recorded and patients were also assessed postnatally adequately.

Results: Among 83 patients the most common finding was mild pelviectasis of kidney (n=49), hydronephrosis(n=13), neurogenic bladder(n=5), renal agenesis unilateral(n=4), bilateral(n=2), multicystic dysplastic kidney(n=4), horseshoe kidney(n=2), cloacal anomaly(n=2). On postnatal follow-up, 7 died due to major anomalies, 2 of the patients preferred to terminate their pregnancy. 20 of the patients under follow up of pediatric department. 54 patients either removed from follow up due to regression of pelviectasis or could not be assessed postnatally since they did not come to our hospital for follow-up.

Conclusion: Fetal magnetic resonance imaging is an important tool in the diagnosis of fetal genitourinary pathologies, it plays an important role on defining the anomaly in details and on detecting additional anomalies and guides for patient management.

SS5.04 - DIAGNOSTIC VALUE OF FETAL MRI IN EVALUATING FETAL URINARY ANOMALIES Behairy N. 1, Shalaby L. 1, Mohamed N. 2, Hamed S. 1, Noah O. 3, Abd El Kader M. 3, Abd El Raof M. 3 Cairo University Radiology Cairo-Egypt 1 El Galaa Hospital Radiology Cairo-Egypt 2 Cairo University Obstetric and Gynecology Cairo-Egypt 3

Objective: To evaluate the contribution of adding MRI findings to sonographic data when assessing fetal urinary tract anomalies and to determine how this addition may affect the management of pregnancy.

Methods :We examined 27 fetuses with sonographically suspected congenital urinary tract anomalies by 2D/3D ultrasound, Doppler and MRI. The gestational age range was 18-36 weeks. 37% of the women were in the second trimester while 63% were in their third trimester. The diagnosis was confirmed by postnatal ultrasound in born babies and autopsy in still born or abortus fetuses.

Results: We found different urinary tract anomalies. Bilateral infantile autosomal recessive polycystic renal disease (n=8), unilateral infantile autosomal recessive polycystic renal disease (n=2), Obstructive urapathy (n=8), Bilateral renal agenesis (n=3), Bilateral enlarged multicystic dysplastic kidneys (n=5), Unilateral enlarged multicystic dysplastic kidneys (n=1) and Renal failure (n=1). MRI changed the US diagnosis in 6 cases (22%) and added information in 4 cases (15%). MRI confirmed US diagnosis in 17 fetuses. Ultrasound was superior to MRI in one case of renal failure. Associated extrarenal anomalies were detected in nine cases (33.3%). 13 lethal renal anomalies were included in this study. The diagnosis was confirmed by postnatal US or CT in viable babies and autopsy in still birth or abortus.

Conclusion: Fetal MR imaging should be used as a complementary modality to US in diagnosing fetal urinary abnormality in which US findings are inconclusive or equivocal.

www.esur2013.org 106 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS5.05 - ROLE OF MRI IN THE DIAGNOSIS OF FETAL ANOMALIES. Gündoğdu E. 1, Yiğit H. 1, Ergun E. 1, Şimşek B. 1, Turgut A. 1, Koşar P. 1 Ankara Training and Research Hospital Radiology Ankara-Turkey 1

Objective: Aim of the present study is to assess the role of MRI in the diagnosis fetal anomalies and to investigate whether the technique improves the accuracy of US for the relevant evaluation.

Materials and Methods: 37 cases referred for fetal MRI examination based on the detection (or suspicion) of fetal anomalies were included. Gestational age range was 16-36 weeks. All cases underwent US examination followed by fetal MRI in one week. Postpartum follow-up was performed in 27 cases.

Results: The diagnosis by US was confirmed in 8 cases whereas additional anomalies having been missed by US were detected in 9 cases. On the other hand, the diagnosis was changed in 18 cases based on MRI findings. Nevertheless, MR revealed no abnormal finding in 6 cases having US findings consistent with various fetal anomalies. According to the results of postnatal follow up, MRI provided more information in 19 patients compared to US implying that the diagnosis by the previous modality was improved by MRI.

Conclusion: Fetal MRI, having a complementary role to US, is a valuable imaging tool for the diagnosis of fetal abnormalites and can be used as a problem solving technique in challenging cases

SS5.06 - CHOROID PLEXUS SEPARATION IN FETUSES WITHOUT VENTRICULOMEGALY: POSTNATAL OUTCOME Tanrıvermiş Sayıt A. 1, İpek A. 2, İdilman İ. 2, Karaoglanoglu M. 2 Samsun Gazi State Hospital Radiology Samsun-Turkey 1 Ankara Ataturk Education and Research Hospital Radiology Ankara-Turkey 2

Objective: The aim of this study was to evaluate the fetuses with choroid plexus separation without ventriculomegaly in terms of associated anomalies, behavior of the separation during follow up and postnatal outcome.

Material and Methods: Between January 2008 and December 2012, 172 fetuses with choroid plexus separation without ventriculomegaly were included in this prospective study. Obstetric ultrasonography was performed between 2-4 week intervals and detailed physical and neurological examinations were performed after the delivery. Fetuses were divided into normal and abnormal subgroups according to the outcome. Independent samples t-test was used for statistical analysis.

Results: Sixteen fetuses (9.3%) were included in abnormal outcome group and 156 fetuses (90.7%) were included in normal outcome group. Both initial mean lateral ventricul diameter and initial mean choroid plexus separation were higher in abnormal group (9.36 mm vs, 8.58 mm and 4.81 mm vs, 3.34 mm, respectively; p< 0.001). Most of the fetuses in abnormal group had a choroid plexus separation above 4 mm (87.5%). Resolution rate of choroid plexus separation was higher in choroid plexus separation below 4 mm in our study (92.8% vs, 50%). In the follow up examinations, separation resolved in 145 of 172 fetuses (84.3%).

Conclusions: Choroid plexus separation without ventriculomegaly often resolves within the third trimestır and does not affect postnatal outcome. However, it can be associated with various congenital anomalies especially when the separation is above 4 mm. So these fetuses should be evaluated carefully and followed up with short intervals.

107 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS5.07 - DIAMETER DIFFERENCES IN FETAL UMBILICAL ARTERIES AFFECT DOPPLER FINDINGS OF THE COMMON ILIAC ARTERIES Tanrıvermiş Sayıt A. 1, İpek A. 2, İdilman İ. 2, Karaoglanoglu M. 2 Samsun Gazi State Hospital Radiology Samsun-Turkey 1 Ankara Ataturk Education and Research Hospital Radiology Ankara-Turkey 2

Objective: This study aimed to investigate any differences between the resistive index values at the common iliac arteries of fetuses demonstrating different umbilical artery diameters. Patients and Methods: Between January and July 2010, 165 singleton pregnancies which admitted at our clinic for obstetric ultrasound screening at early second trimester and have follow up ultrasonography at third trimester included in this study. The umbilical artery diameters and common iliac artery flow parameter (resistive index) were measured at both second and third trimester screening. Paired t-test was used for comparing dominant and non-dominant common iliac arteries resistive index values.

Results: The incidence of diameter difference between the two umbilical arteries was found to be 6.7%. Eleven of the 165 patients demonstrated a diameter difference greater than 25% (95th percentile) between their two umbilical arteries at the 18th to 22nd gestational week measurement. Color Doppler ultrasound examination of these 11 cases showed that the resistive index values of the non-dominant common iliac artery were significantly higher than that of the dominant common iliac artery (p<0,001).

Conclusions: Our study revealed that resistive index values of the non-dominant common iliac artery at the hypoplastic umbilical artery group were higher than that of the contralateral dominant common iliac artery. However, there was no clinical significance for the fetal outcome.

www.esur2013.org 108 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 6: Stone Disease

SS6.01 - IMPACT OF 4TH GENERATION ITERATIVE RECONSTRUCTION TECHNIQUES ON IMAGE QUALITY IN ULTRA LOW-DOSE MDCT FOR SUSPECTED UROLITHIASIS Regier M. 1, Veldhoen S. 1, Laqmani A. 1, Henes F. 1, Adam G. 1 University Medical Center Hamburg-Eppendorf Department of Diagnostic and Interventional Radiology Hamburg-Germany 1

Object: To intraindividually compare and evaluate the influence of the 4th generation iterative reconstruction (IR) technique iDoseTM on ultra low-dose MDCT of the upper urinary tract with regard to anatomical delineation and stepwise artifact reduction.

Method: In 32 consecutive patients suspected of urolithiasis the raw data of unenhanced 256 slice MDCT scans (120 kV, 30 mAs, mean CTDIvol: 1.5 mGy) were reconstructed using iDose4TM (Philips, Best, the Netherlands). iDoseTM level settings were varied between 0 (exclusive filtered-back-projection), 2, 4 and 6. Image analysis was independently performed by three blinded radiologists. A 4-point grading scale was applied regarding the depiction of details of the upper urinary tract and the degree of artifacts. The signal- to-noise ratio was assessed for each data set. Statistical evaluation included weighted kappa-analysis and Wilcoxon-test.

Results: Highest image quality was assessed applying iDoseTM level of 4 (mean score:3.38). Even at the lower iDoseTM level of 2 (mean score:2.78) the ratings were superior to standard filtered-back-projection (iDoseTM level 0; mean score:2.11). However, applying the highest iDoseTM level of 6 a blotchy appearance of anatomical contours was observed leading to a distinct drop in average image quality (mean score:3.16). Inter-rater reliability was excellent in all cases (Κ, 0.91; p<0.01).

Conclusion: Iterative reconstruction of the 4th generation seems to be a powerful tool for improvement of image quality in ultra low-dose MDCT of the upper urinary tract. Even at relatively low iDoseTM levels higher image quality with substantial reduction of streak artifacts compared to the filtered back-projection can be achieved.

SS6.02 - LOW-DOSE DUAL-SOURCE DUAL-ENERGY CT FOR UROLITHIASIS: FEASIBILITY STUDY Pansini M. 1, Benz M. 1, Morsbach F. 2, Szucs-Farkas Z. 3, Stolzmann P. 2, Subotic S. 4, Bongartz G. 1, Schindera S. 1 University of Basel Hospital Department of Radiology Basel-Switzerland 1 University Hospital Zurich Institute of Diagnostic and Interventional Radiology Zurich-Switzerland 2 Hospital of Biel Department of Radiology Biel-Switzerland 3 University of Basel Hospital Department of Urology Basel-Switzerland 4

Purpose: To assess the detectability and characterization of renal stones with a dual-energy protocol at various radiation dose in a phantom.

Methods: A custom kidney phantom containing 18 renal stones (5 uric acid (UA)-containing and 13 non- UA-containing; diameters 4-12 mm) was placed in a water container that mimicked an intermediate-sized patient. The phantom was scanned with the vendor-provided dual-energy protocol (Somatom Definition Flash, Siemens) (tube-A, 100 kVp, 210 reference-mAs; tube-B, 140 kVp, 162 reference-mAs) (protocol A). The phantom was also scanned with seven dose-optimized protocols in which the reference mAs setting of tube A was reduced stepwise by 20 mAs low to 70 mAs (protocol B to H, respectively). Postprocessing software characterized the stones as UA- and non-UA-containing. Detection of the stones was performed by two radiologists in consensus. The radiation dose was assessed with the volume CT dose-index (CTDIvol). The image noise and the contrast-to-noise ratio (CNR) were calculated.

Results: The CTDIvol measured 15.6, 14.4, 13.2, 11.9, 10.5, 9.2, 7.6, and 6.0 mGy (protocol A to H, respectively). As the radiation dose decreased, the noise increased from 7.9 to 14.3 HU and the CNR decreased from 4.0 to 2.1 (protocol A to H, respectively). The sensitivity to detect stones was 100% for all protocols. Renal stones were correctly characterized in all protocols, except in protocol H, where two UA- containing stones were falsely classified as non-UA-containing stones.

Conclusion: The radiation dose of the vendor-provided dual-energy protocol for urolithiasis can be reduced by up to 50% while maintaining detectability and characterization of urolithiasis.

109 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS6.03 - IMPACT OF URETERAL JET FLOW ON URINARY TRACT STONE FORMATION Celik S. 1, Altay C. 2, Ongun S. 1, Uz G. 2, Bozkurt O. 1, Demir O. 1, Secil M. 2, Aslan G. 1 Dokuz Eylul University Urology Izmir-Turkey 1 Dokuz Eylul University Radiology Izmir-Turkey 2

Objective: To investigate the relationship between ureteral jets measured by color Doppler sonography and stone disease.

Method: Patients between 18-40 ages who admitted to our clinic between August 2012- June 2013 with flank pain were consecutively included in the study. Bilateral ureteral jet measurements were performed with Doppler sonography after one hour oral hydration with 1000 ml of water to all patients, then all underwent non-contrast enhanced CT. Subjects were grouped as nonobstructive unilateral calyx calculi (Group 1) and control group who have no signs of stone disease (Group 2). Mean jet flow (JETmean) and jet flow patterns (JETpattern) were determined and compared between the renal units of these two groups.

Results: JETmean were significantly lower in group 1 compared to group 2 (p<0.05). Median JETmean was 9 cm/s in group 1; further analysis for a JETmean lower than a cut-off value of 9 cm/s gave an Odds ratio of 19.3 for stone risk. It was also found that this value had a 61.3% sensitivity and 87.5% specifity for stone formation. Also 95% patients with continuous jet flow pattern had stone disease determined on NCCT.

Conclusions: Lower ureteral jet flow which refers to decreased ureteral peristaltism seems to have a role in stone formation and subjects with JETmean 9 cm/s need close follow-up for stone formation. Continous jet- flow pattern might be a predictor of stone disease. Ureteral jets can be used for the diagnosis and follow-up of stone disease.

SS6.04 - ALTERNATIVE AND INCIDENTAL FINDINGS ON UNHANCED MDCT IN PATIENTS WITH FLANK PAIN: PREVALENCE AND CHARACTERISTICS Parlak S. 1, Altın L. 1, Erdogan A. 1, Kaplanoglu H. 2, Rona G. 1, Kaplanoglu V. 1 Numune Education and Research Hospital Radiology Ankara-Turkey 1 Dışkapı Yıldırım Beyazıt Education and Research Hospital Radiology Ankara-Turkey 2

Objective:To investigate alternative causes of flank pain and frequency and charasteritics of incidental findings detected on unenhanced multidetector computed tomography(MDCT).

Method:Sevenhundred nineteen patients (427 male, 292 female, mean age 47) with suspected urolithiasis underwent unenhanced 64 slice MDCT. The images were analysed retrospectively. Urinary stones and their effects were evaluated, but also alternative and incidental findings were noted. These incidental findings were classified as major, moderate and minor according to clinical importance.

Results:Urinary stones were found in 451(62,7%) patients. Alternative or incidental findings were found in 345 (48%) patients. Number of major, moderate and mınor findings were 56, 162 and 320 respectively. The most common findings were renal cortical cysts in 70(9,7%) patients. Most of major findings were malignancies. The most frequent malignancy were bladder carsinoma in 6(0,8%) patients. We determined 6(0,8%) lomber disc hernia, 12(1,7%) spondilolisthesis, 8(1,1%) compression fracture and 10(1,4%) scoliosis with the help of sagittal and coronal reformatted images. CONCLUSION:Our incidental findings rate is higher than the literature. Seperating them to major, moderate and mınor, improvement in the CT technology and awareness among the radiologists may be the cause of this rise. As our major findings rate was similar to literature. There were not much skeletal findings in similar studies. We sugges that coronal and sagittal reformatted images contribute to detect these skeletal findings. Although stone disease is the most common cause of flank pain, we have to be aware of alternative diseases that can create simial flank pain and need rapid treatment.

www.esur2013.org 110 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS6.05 - X-RAY ENDOVASCULAR TREATMENTS OF VASCULAR ERECTILE DYSFUNCTION OB Zhukov, OI Apolihin, AV Sivkov,V.A.Ukolov “Research Institute of Urology, Ministry of Public Health” (Moscow)

Objective: Penile prosthesis is the method of choice in the surgical treatment of vascular erectile dysfunction . However, in early stages of disease it seems appropriate to apply a new endovascular treatment.

Method: We have operated 14 patients with vascular ED at the age of 25-48 (mean age 36.4 + -7.4). 9 of them had veno-occlusive erectile disruption, 3 of them had arterial insufficiency of cavernous body and 2 of them were with arteriovenous ED. The diagnosis is based on Doppler ultrasound study of the corpora cavernous of the penis with penile farmtests, Multispiral computed pharmacocavernosography and multispiral computed tomography of the arteries of the pelvis . The study is performed on the unit “Toshiba Aquilion 64”.

Results: We have made vesels stanting in isolated proximal atherosclerotic lesion iliac vessels. Unilateral puncture access was used. Baloon dilatation was used when defeat of pudendal arteries was length .We used baloon catheter Sim2 № Fr 5 with the pressure 10 atm in balloon and time for exposition was 4-5min . The operation was performed on the periphery of the proximal area of the vessel. In vienocclusive abnormality of erection in the form of abnormal venous drainage of the corpora cavernosa of the penis proximal direction we were taking venous embolization.

Conclusions: These techniques of operations are effective ways of sexual rehabilitation of patients with erectile dysfunction.

SS6.06 - MAGNETIC RESINANCE IMAGING AND DIFFUSION WEIGHTED MAGNETIC RESONANCE IMAGING AS A PROBLEM SOLVING IMAGING MODALITY IN DIFFERENT TESTICULAR LESIONS Afifi -hafez a. 1 Faculty of Medicine Radiology Alexandria-Egypt 1

Objective : To assess the role of MRI and MRI Diffusion weighted imaging in the characterization of testicular lesions as well as in assessment of undescended testes regarding location and internal architexture .

Subjects And Methods: MRI was performed on 32 patients referred because of either testicular swellings or for non palpable testis which was confirmed clinically and sonographically. Both T1- and T2-weighted sequences were performed with a 1.5-T closed magnet MRI unit. Gadolinium chelate was administered IV in some cases and DWI was applied followed with ADC measurment. We recorded the presence of a lesion and whether the histologic diagnosis of testicular malignancy could have been predicted on the basis of MRI features. For testicular neoplasms, local extension of disease was studied. The MRI findings were correlated with the surgical and histopathologic results.

Results: Histologic examination revealed 24 intratesticular lesions and 8 cases presented with unpalpable testis , 18 out of 24 (75%) of which were malignant and six (25%) were benign or inflammatory. Twenty malignant testicular tumors (80%) were confined within the testis, 2 (10%) had invaded the testicular tunicae or epididymis, and two (10%) had invaded the spermatic cord. The sensitivity and specificity of MRI in differentiating benign from malignant intratesticular lesions were 100% and 87.5% .

Conclusion: MRI is a good diagnostic tool for the evaluation of testicular lesions . It is highly accurate in the preoperative characterization and local staging of testicular neoplasms as well as in detecting site of undescended testis .

111 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS6.07 - MULTIMODALITY IMAGING OF SPERMATIC CORD ABSESS Sivrioglu A. 1, Incedayı M. 2, Saygın H. 2, Sonmez G. 2 Aksaz Military Hospital Radiology Mugla-Turkey 1 GATA Haydarpasa Teaching Hospital Radiology Istanbul- Turkey 2

Case: A 21-year-old man was admitted to the urology department due to swelling and pain in the left inguinal region. On initial physical examination, he was slightly febrile, and areas of induration with tenderness were palpated in the left inguinal region and left hemiscrotum. On Ultrasound (US) left epididymo-orchitis and expansion of the left inguinal canal were seen. In addition, a cystic tubular mass with wall thickness that had displaced the bladder was seen in the left hemipelvis. Contrast-enhanced CT revealed a cystic tubular mass with marked marginal enhancement from the left inguinal canal to the left seminal vesicle. On MRI the finding of left epididimo-orsitis and expansion of the left spermatic cord with tubular fluid collection was determined. On contrast-enhanced MRI the left spermatic cord abscess was confirmed. Abscess formation of the prostate tissue was not observed. Moreover, the mild wall enhancement of the seminal vesicle and mild cystic dilatation were seen.

Discussion: Spermatic cord abscess is generally secondary to inflammation of the prostate. In the literature spermatic cord abscesses due to E. coli and candida have been determined in two different cases1, 2. To our knowledge, ours is the third report in the English-language literature. However, ours is the first case that did not have chronic diseases.

www.esur2013.org 112 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 7 : Prostate Cancer Imaging - II

SS7.01 - IMPACT OF PELVIC BIOMETRIC MEASUREMENTS, VISCERAL AND SUBCUTANEOUS ADIPOSE TISSUE AREAS ON TRIFECTA OUTCOMES AFTER OPEN RADICAL PROSTATECTOMY Ongun S. 1, Demir O. 1, Gezer N. 2, Gurboga O. 1, Secil M. 2 Dokuz Eylul University School of Medicine Urology Izmir-Turkey 1 Dokuz Eylul University School of Medicine Radiology izmir-Turkey 2

Objective: To investigate the impact of pelvic biometric measurements, visceral and subcutaneous adipose tissue areas on trifecta outcomes (cancer control, continence, and potency) after open radical retropubic prostatectomy.

Method: A retrospective study was performed on 270 patients who were diagnosed as clinically localized prostate cancer between 2005-2011 and had computed tomography imaging before radical retropubic prostatectomy operations. Pelvic bony and soft tissue measurements, the area of visceral and subcutaneous adipose tissue calculations were performed. Patients were evaluated for trifecta outcome on univariate and multivariate analyses. Subgroup analysis was performed for prostate volume, body mass index (BMI) and D’Amico risk classification.

Results: The age of the patient, pre-operative prostate specific antigen value, symphysis pubis angle and the ratio of width of prostate to bony femoral width (prostate/femoral width), demonstrated significance for trifecta outcomes (P < 0.05). Soft tissue index (ratio of soft tissue width of narrowest distance between the levator muscles to apical depth of the prostate) was statistically significantly lower when prostate volume > 60 cm3 (P < 0.05). Visceral adipose tissue area and prostate/femoral width showed significance when BMI < 25 kg/ cm2 (P < 0.05). In the low risk group of D’Amico classification, prostate/femoral width was significantly lower (P < 0.05).

SS7.02 - EFFICACY OF THE EUROPEAN SOCIETY OF URORADIOLOGY’S PI-RADS CLASSIFICATION SYSTEM IN PRE-BIOPSY PROSTATE MRI Patel C. 1, Jacob A. 2, Balasubramanian M. 2 University Hospital of North Staffordshire Urology Stoke-on-Trent-United Kingdom 1 University Hospital of North Staffordshire Radiology Stoke-on-Trent-United Kingdom 2

Objective: In February 2012, The European Society of Uroradiology (ESUR) published guidelines on reporting multiparametric MRI of the prostate. Our 1 year prospective study from April 2012 to April 3013 evaluates the accuracy of ESUR’s prostate multi-parametric MRI scoring system (PI-RADS) in detecting clinically significant prostate cancer.

Methods: 75 patients with raised PSA had pre-prostate biopsy MRI. Diffusion weighted images were acquired along b0,b100,b400,b800,b1600 gradient with corresponding apparent diffusion coefficient maps. Clinically significant cancer probability was recorded using the five-point PI-RADS scale (1 [significant cancer highly unlikely] to 5 [significant cancer highly likely]). Histological data from subsequent TRUS prostate biopsy (4 quadrant) was then used to evaluate the accuracy of MRI.

Results: A total of 311 prostate regions from the 75 patients were assessed. Mean age was 65.91 (+/- 6.04) years and PSA 10.46 (+/- 6.56) ng/ml. For the 97 regions with a PI-RADS score ≥4, MRI had a sensitivity of 75% (positive predictive value 64%). 209 quadrants with score ≤3 had a negative predictive value of 85%. Of the false negatives, only 8 regions (3.8%) had a Gleason score of greater than 6 (six 3+4; two 4+4) and 1 (0.5%) had tumour length greater than 10mm. Total percentage cancer involvement was less than 50% in all false negatives. MRI’s negative predictive value for clinically significant cancer was 98.6%.

Conclusion: PI-RADS is an effective scoring system. Our study demonstrated encouraging trends in the negative predictive value of clinically significant prostate cancer, which has significant implication in treatment planning and active surveillance.

113 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS7.03 - FIRST RESULTS OF MRI-TARGETED TRUS-GUIDED TRANSPERINEAL FUSION BIOPSIES TO RESTRATIFY PROSTATE CANCER PATIENTS UNDER ACTIVE SURVEILLANCE Kuru T. 1, Roethke M. 2, Tosev G. 1, Schlemmer H. 2, Hohenfellner M. 3, Hadaschik B. 3 UniversityHospital Heidelberg Department of Urology Heidelberg-Germany 1 German Cancer Research Center Department of Radiology Heidelberg-Germany 2 UniversityHospital Department of Urology Heidelberg-Germany 3

Objectives: To evaluate the value of MRI-targeted TRUS-guided transperineal fusion biopsies in patients under active surveillance (AS). The adequate extension of bioptic prostate sampling to safely include patients into AS will be discussed.

Methods:We performed stereotactic prostate biopsies using the BiopSee® platform on 48 men on AS with unifocal Gleason-score 6 prostate cancer (PC) after standard 12-core-TRUS biopsy. Median number of biopsies taken per patient was 25 (12-30). A purpose-designed questionnaire was sent out to all patients for disease-specific follow-up.

Results: In 40 of 48 (83%) patients with former proof of low-volume Gleason-score 6 PC, biopsy samples showed PC. 21 of 48 (43.7%) biopsy proven PC were upgraded to Gleason-scores >6. 4 of 19 patients with Gleason-score 6 showed bilateral tumor envolvement at biopsy. In MRI-lesions marked as PIRADS 4/5, the tumor detection-rate was 89.5% (17/19); 13 of these with Gleason-scores ≥7. 16 of 22 men (72%) who were described as PIRADS 1/2 on MRI showed no tumor progression. 12 patients underwent radical prostatectomy after biopsy. 11 of these patients had pT2c pN0 disease. Two of those patients were upgraded from Gleason-score 6 to 7 (3+4).

Conclusions: Standard 12-core-TRUS-guided biopsies underestimate the Gleason-score in a large percentage of patients with unifocal low-volume Gleason score 6 PC. Image-guided transperineal prostate saturation biopsies enable a more reliable risk classification and therefore increase safety for men entering AS. MRI alone does not seem to be precise enough yet.

SS7.04 - PI-RADS AND GLEASON SCORES: ARE THEY ASSOCIATED? EXPERIENCE IN 244 OPERATED PATIENTS. Petralia G. 1, Alconchel A. 1, Alessi S. 1, Summers P. 1, Raimondi S. 2, Musi G. 3, Renne G. 4, De Cobelli O. 3, Bellomi M. 1 IEO Radiology Milan-Italy 1 IEO Epidemiology and Biostatistics Milan-Italy 2 IEO Urology Milan-Italy 3 IEO Anatomopathology Milan-Italy 4

Objective: to investigate whether PI-RADS and Gleason scores are associated. Methods: Two hundred forty-four consecutive biopsy-proven prostate cancer patients underwent multiparametric magnetic resonance imaging (mp-MRI) of the prostate before robotic-assisted radical prostatectomy. The mp-MRI exams, performed at 1.5-T (Avanto, Siemens, Erlangen, Germany) using a pelvic phased-array coil, included: axial, coronal and sagittal T2-weighted images, axial diffusion-weighted images (b-values of 0, 500 and 1000 s/mm2 in three orthogonal directions), and axial dynamic contrast enhanced MRI (temporal resolution 9.4s, repeated for 5min, 0.2mL/kg contrast agent at 3mL/s). Two radiologists prospectively analyzed the mp-MRI exams of the prostate according to 2012 ESUR prostate MR guidelines using the PI-RADS classification for structured reporting. Each lesion was given a PI-RADS score based on location, size and probability of extra-prostatic disease. The highest lesion PI-RADS score for each patient was compared with the Gleason score (GS) at final pathology report using a Chi-square test and the Mantel- Haenszel test for trend. For each PI-RADS score, the odds Ratio (OR) with 95% Confidence Interval (95%CI) was calculated to estimate the risk of having post GS≥7.

Results: we found a significant association between PI-RADS and Gleason scores (p-value <0.0001), and that GS increased with increasing PI-RADS score (p-value for trend <0.0001). Patients with PI-RADS=4 had more than threefold higher probability of having GS≥7 than patients with PI-RADS≤3 (OR: 3.46; 95%CI: 1.26-9.52).Patients with PI-RADS=5 had more than 18-fold higher probability of having GS≥7 than patients with PI-RADS≤3 (OR: 18.40; 95%CI: 6.81-49.70). Conclusion: PI-RADS and Gleason scores were strongly associated in our cohort.

www.esur2013.org 114 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS7.05 - THE PREDICTIVE VALUE OF APPARENT DIFFUSION COEFFICIENT CHANGES IN PROSTATE CANCER PATIENTS TREATED WITH RADIOTHERAPY Erbay G. 1, Onal C. 2, Guler O. 2, Karadeli E. 1, Koc Z. 1 Baskent University Faculty of Medicine Department of Radiology Ankara-Turkey 1 Baskent University Faculty of Medicine Department of Radiation Oncology Adana-Turkey 2

Objective: To investigate the feasibility of diffusion-weighted MRI (DWI) as a reproducible change indicator in prostate cancer patients treated with radiotherapy (RT).

Methods: Fifty-four consecutive patients with biopsy-proven prostate cancer underwent DWI before and median 4.0 months (ranged 3.0-5.3) after RT. Patients with high- and intermediate-risk patients received hormonotherapy before, during and after RT. The mean apparent diffusion coefficient (ADCmean) values were measured at each DWI, and comparison was performed in pre- and post-treatment DWI. Additionally comparison was made according to risk group and use of hormonotherapy. Results: The risk groups constitute; 20 patients (37%) low risk, 13 patients (24%) intermediate risk, and 35 patients (39%) high risk. Thirty-five (65%) patients received hormonotherapy and 19 patients (35%) did not. The mean pretreatment ADCmean value was significantly lower compared to post-treatment value (0.82±0.13×10−3/mm2/s vs. 1.09±0.14×10−3/mm2/s; p<0.001). The mean pretreatment ADCmean values for low, intermediate and high risk patients were 0.89±0.10×10−3/mm2/s, 0.84±0.12×10−3/mm2/s, and 0.74±0.12×10−3/mm2/s, respectively. Mean change in pre- and post-treatment ADC value was 24% (ranged 4% - 46%). The ADCmean value changes were 20±2%, 22±3%, and 30±2% for low, intermediate and high risk patients, respectively. Concurrent hormonotherapy and RT significantly increase the ADCmean changes compared to RT alone (26±11% vs. 21±8%; p=0.04).

Conclusions: The ADC measured in DWI, as a reproducible biomarker, has the potential to evaluate the therapeutic changes of prostate cancer to RT. Combined hormonotherapy and RT in intermediate- and high- risk patients produced more changes in ADC compared to RT alone in low risk patients.

SS7.06 - THE CORRELATION OF PHARMACOKINETIC PARAMETERS OF DYNAMIC CONTRAST- ENHANCED MR IMAGING IN TUMORS AND NORMAL PROSTATE GLAND. Erbay G. 1, Onal C. 2, Guler O. 2, Koc Z. 1 Baskent University Faculty of Medicine Department of Radiology Ankara-Turkey 1 Baskent University Faculty of Medicine Department of Radiation Oncology Adana-Turkey 2

Objective: To investigate the correlation of perfusion parameters measured in normal tissue and tumor in dynamic contrast enhanced MR imaging (DCE-MRI) in prostate cancer patients.

Methods: Thirty-three patients with prostate cancer underwent DCE-MRI before radiotherapy (RT). A total of 62 lesions (34 peripheral lesions, 28 central lesions) were evaluated. DCE-MRI parameters were calculated in the tumor and the gland where the tumor is located. The mean and median values of Ktrans, ve, kep and AUC were measured, and correlation between tumor and normal prostate gland was assessed.

Results: The mean ± SD values of Ktrans, ve, kep for tumor were 4x10-3 ± 2x10-3, 0.438 ± 0.163 and 0.108 ± 0.072, respectively and the median values were 4x10-3 ± 2x10-3, 0.443 ± 0.165 and 0.105 ± 0.065. The mean ± SD values of Ktrans, ve, kep for prostate gland were 0.9x10-3 ± 0.5x10-3, 0.294 ± 0.119 and 0.033 ± 0.016, respectively and the median values were 1x10-3 ± 0.6x10-3, 0.311 ± 0.118 and 0.038 ± 0.023. There were significant correlations in Ktrans, ve, and AUC between tumor and prostate gland for peripheral lesions for both peripheral and central lesions, whereas significant correlation for kep was observed only for peripheral lesions.

Conclusion: Ktrans, ve, and AUC may help to evaluate the characteristics of tumor in prostate cancer. However larger, prospective and more definitive studies are required.

115 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS7.07 - VALIDATION OF THE SIMPLIFIED IVIM APPROXIMATION IN PROSTATE CANCER IMAGING Carbone S. 1, Belmonte G. 2, La Penna A. 1, Semeraro L. 3, Curion A. 2, Banci Buonamici F. 2, Volterrani L. 1 University Hospital of Siena Department of Radiology Siena-Italy 1 University Hospital of Siena Department of Medical Physic Siena-Italy 2 University Hospital of Siena Department of Radiotherapy Siena-Italy 3

Objective: To compare a simplified model (SM) and intravoxel inchoerent motion (IVIM) model in the extrapolation of diffusion parameters (Dp) (perfusion fraction f(p) and D) in DWI-MR Imaging of prostate gland.

Method: Ten consecutive patients affected by prostate cancer were scheduled for DW-Imaging using 6 different b-values (interval 10-1000 sec/mm2). Neoplastic and healthy tissues of prostate were delineated by 3D contouring on a T2-weighted image then registered to DWI volumes; a correction for patient and organ motion and for eddy currents distortions were applied. A bi-exponential fit in all voxels of the prostate was used to extrapolate DpIVIM. Six non diffusion weighted images were used to build a standard deviation map used as statistical weights in the non-linear fit ( R2>0.99). DpIVIM constitute the gold standard for corresponding ones derived by the simplified method (DpSM), applied for each pair of b-values in the whole sample. Correlation was evaluated for the DpSM and DpIVIM. Differences in Dp for normal and tumor tissues were evaluated using the nonparametric Wilcoxon test. A phantom was imaged using 100 b-values from 0 to 1000sec/mm2 to test the quality of scanner.

Results: Simplified method overstimed D and understimated f(p). A better agreement results when using intermediate b-values (600-800sec/mm2). D and f (p) were significantly lower in neoplastic areas compared to normal tissues.

Conclusion: In prostate tissues the simplified model is valid for b-values >600sec/mm2 so attention must be paid to choose the acquisition protocol. Dp measurements significantly depend on b-values.

SS7.08 - EVOLUTION OF MRI SIGNAL INTENSITIES AND ADC VALUES IN PROSTATE GLAND AND PROSTATE CANCER POST NON THERMAL IRREVERSIBLE ELECTROPORATION Studniarek M. 1, Siekiera J. 2, Moskal-Szabo J. 3, Wronczewski A. 2, Pienkowska J. 1 Medical University Radiology Gdansk-Poland 1 Oncological Center Urology Bydgoszcz-Poland 2 Oncological Center Diagnostic Imaging and Interventional Radiology Bydgoszcz-Poland 3

Objective: The purpose of this study was to evaluate the evolution of ADC values and T1 and T2 SI in high grade prostate cancer after nonthermal irreversible electroporation (NTIRE). 69-year old male with diagnosed prostate cancer (Gleason 9), was qualified to whole prostate gland NTIRE. We applied four step procedure to cover whole prostate gland by the electropulses. Seven MRI of prostate gland (1.5T, T1 and T2, DWI with b values 0, 100, 500 and 800s/mm2) were performed. The T1, and T2 SI’s as well as ADC of both prostate gland and cancer were measured in chosen ROIs before and on 1st, 2, 4, 30, 90, and 180 day post ablation. In the prostate cancer we observed immediate, significantly growing ADC values of about 48, 51, 54, 121, 64 and 63% of initial ones, respectively. On the 1, 2nd and 4th day after NTIRE there was the slight increase of ADC values in not invaded prostate gland (22, 17 and 21% respectively). One, three and six months later they have remained stable. The volume of the whole prostate gland increased after treatment and then continuously decreased up to 40% of initial one (114, 100, 110, 100, 75 and 41% of initial volume on the day 1, 2, 4, 30, 90 and 180 post NTIRE, respectively)

Conclusions: ADC value within the prostate cancer is significantly growing immediately after IRE Prostate volume is growing in the early post IRE period, and is going down starting one month after IRE leading to significant prostate gland atrophy.

www.esur2013.org 116 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 8 : Functional Imaging

SS8.01 - REAL-TIME SONOGRAPHIC DEPICTION OF TWISTED VASCULAR PEDICLE IN OVARIAN TORSION Lee E. 1, Kim Y. 2 Ajou University Hospital Radiology Suwon-Korea, South 1 Cheil General Hospital Radiology Seoul-Korea, South 2

Objective: To assess the depiction of twisted vascular pedicle in ovarian torsion using real-time ultrasonography (US).

Method: 46 patients with surgically proved torsion were examined with transvaginal and transabdominal US. The grayscale and color Doppler images were acquired in real-time to scan through the whole of twisted vascular pedicle by moving the probe from uterus to ovary. The US findings of twisted vascular pedicle were evaluated for the diameter, the degree of torsion, and the presence of blood flow itself. Concomitant ovarian and tubal torsion were present in 36 patients and isolated tubal torsion in 10 patients. 37 patients had underlying masses including 24 ovarian tumors and 13 paratubal cysts.

Results: Real-time clip images clearly demonstrate the overall configuration of the twisted vascular pedicle along the entire course in all 46 patients, as well as the blood flows through twisting vessels. The mean diameters of twisted vascular pedicle were 2.1 cm (range, 1.2 - 3.7 cm). The degree of torsion ranged from 180 degrees (1/2 complete turn) to 1440 degrees (4 complete turns). Both arterial and venous flows within the twisted vascular pedicle were detected in 32 of 46 torsion patients and only arterial flows were present in 4 patients. The remaining 10 patients showed no blood flow in the intrapedicular vessels.

Conclusion: The depiction of twisted vascular pedicle on real-time US could help to identify the twisted vascular pedicle and its flow, which may facilitate early confident diagnosis of ovarian torsion.

SS8.02 - SONOGRAPHIC INCIDENCE AND FINDINGS OF RENAL CYST Dilli A. 1, Karabacak O. 2, Yesil S. 2, Fırat H. 1, Ayaz U. 3, Celtikci P. 1, Hekimoglu B. 1 S.B. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 1 S.B. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Urology Ankara-Turkey 2 S.B. Mersin Kadın Doğum ve Çocuk Hastalıkları Hastanesi Radiology Mersin-Turkey 3

Introduction: Simple renal cysts are frequent among adult population especially in elderly. Classification is essential for treatment and follow-up of the patients. In our study we aim to put forth incidence of the renal cyst in patients who admitted of various reasons and evaluated with abdominal ultrasonography (US). ultrasonography classification and correlation of such factors as age and gender to the frequency were also investigated.

Material and Methods: Upper abdominal or urinary tract US was performed in 16272 patients who admitted for various complaints (8863 male, 7409 female, mean age:50.58, age range: 1-98). Sonographic findings (renal cyst number, size, location, Bosniak classification, renal calculi, renal size, renal echogenity and hydronephrosis), age and gender were recorded and evaluated. Findings: Cyst prevalence was found 9.3% in all subjects, 1.8% under the age of 40 (87/4806) and 21.6% over the age of 70 (589/2679). Cyst prevalence increases with age (p<0,001). The mean age of patients with cyst (64.46 ± 13.69) was prominently higher than patients without cyst (50.58 ± 19.216) ( p<0.001). Male to female ratio was 1.73 (female 490/7409:6.6; male 1024/8863:11.5; p<0.001). Majority of the identified cysts were solitary (52%). Age and gender found significantly relevant with renal cysts.

Conclusion: US is an appropriate modality for detection and classification of renal cysts. Renal cyst incidence is relevant with age and gender.

117 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS8.03 - THE ROLE OF TRANSPERINEAL ULTRASOUND IN THE EVALUATION OF FEMALES WITH URINARY INCONTINENCE COMPARED TO URODYNAMIC STUDIES. Wahba M. 1, Elsayed R. 1, Talat S. 1, Yahya A. 1 Cairo university radiodiagnosis Cairo-Egypt 1

Objective:To prospectively evaluate the role of transperineal ultrasound in diagnosis of female with urinary incontinence compared to urodymanic studies as the golden standard.

Methods:Twenty female patients ranging from 24-50 years old clinically diagnosed as urinary incontinence. Fifteen patients out of them were diagnosed as mixed urinary incontinence and 5 patients diagnosed as having stress urinary incontinence.Transperineal ultrasound examination was performed using 6.5MHz end- fire vaginal endoprobe applied to the perineum in axial and sagittal planes. Patients were examined at rest and during different grades of straining.

Results: 40% of the patients (N=8) had negative sonographic findings, while(N=12) 60% had positive findings distributed as follows: Group A: 15%(N=3) patients were diagnosed having urethral hypermobility. Group B: 10%(N=2) patients were diagnosed as having Intrinsic sphincter deficiency(ISD) Group C: 35%(N=7) patients were diagnosed as having both hypermobility and ISD. The degree of agreement between transperineal ultrasound and urodynamic study was very high in group B (100%), in group C (71.5%), while the lowest degree was seen in group A (66.7%).

Conclusion:Our preliminary results in this pilot study suggest that transperineal ultrasound is a simple, easily conducted examination that can be used as screening imaging modality in patients with urinary incontinence to diagnose patients who are in need for further assessment.However, in our department larger number of patients is currently under examination to confirm the above findings.

SS8.04 - RENAL DUPLICATION AND RENAL SIZE RELATIONSHIP IN ASYMPTOMATIC ADULTS MEASURED BY ULTRASOUND Üstüner E. 1, Düşünceli Atman E. 2, Uzun Ç. 1 Ankara University School of Medicine Radiology Ankara-Turkey 1 Ankara Univerrsity School of Medicine Radiology Ankara-Turkey 2

Objective: To detect the rate of renal duplication in asymptomatic adult patients and compare renal sizes of duplicated kidneys with normal kidneys using ultrasound.

Method: Asymptomatic healthy individuals with no known systemic diseases and renal diseases were invited to participate in the study. The kidneys of both sides are examined and renal length, width, breadth, parenchymal thickness are measured by ultrasound. Renal volume was calculated. Normal kidney sizes were compared to duplicated kidney sizes on both sides.

Results: A total of 584 adults were examined. 151 duplicated kidneys (partial and complete) were detected. Duplication rate was 12.9%. Duplicated kidneys were larger in size as compared to normal kidneys (p<0.05) which was most prominent in length measurements. In normal individuals, left kidney was noted to be larger than the right kidney. If both sides were to be duplicated or if a right duplication was present, this causes size discrepancy between kidneys to disappear.

Conclusion: The rate of duplication in asymptomatic adults is higher than expected and duplication causes increase in kidney sizes especially in length. Due to naturally occurring size discrepancy between the right and left kidneys, if both kidneys are duplicated or right kidney is duplicated, kidney sizes on both sides become similar.

www.esur2013.org 118 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS8.05 - KLINEFELTER DISEASE : SONOGRAPHIC TESTIS FINDINGS WITH HORMONAL AND PATHOLOGIC CORRELATIONS L Rocher, Loris Moya, Vincent Izard, Sophie Ferlicot, Marie France Bellin.

Objectives : Klinefelter’s syndrome is the most common chromosomal aberration among azoospermic men, and is associated with major alterations of ultrasound pattern, sometimes misleading to inappropriate surgical decision. The aim is to describe sonographic findings including the follow-up and pathological correlations in patients with surgical exploration.

Methods : scrotal sonography was performed as part of the infertility workup in 64 infertile Klinefelter men. Patients were evaluated for testis volume, parenchymal structure, microlithiasis, and presence of nodules. Echo-pattern alterations have been classified in three groups : coarse or multimicronodular echotexture (group1), widespread hyper- and hypoechoic foci (less than 3mm, group2), dominant nodules (always hypoechoic) upper than 3 mm (group3). Color Doppler was performed and the presence or absence of hypervascularisation was recorded. Testosterone and FSH level were obtained in 53 cases.

Results: No examination was normal. All patients had a reduced testis volume (mean 1.9 cm3/testis). Group 1 included 24 patients, group 2 27 patients, and group 3 13 patients. There was no difference between mosaic or non mosaic status regarding the volume or aspect of the testis. For 5 patients with predominantly hypoechoic nodules, surgical exploration with nodule removal was helped by echo guidance. All were small Leydig cell benign tumors. 11 patients underwent also a testicular biopsy with the aim to obtain spermatozoon; no complete spermatogenesis was ever observed in these patients. The presence of nodules correlated with vascularity, but not with testosterone or FSH levels.

Conclusions : Association of small bilateral testes, testicular nodules, and microlithiasis is highly suggestive of Klinefelter’s syndrome. Because of testosterone insufficiency, orchidectomy for benign lesion should be avoided in these patients. In case of a large hypoechoic nodule, tumorectomy can be recommended.

SS8.06 - CONTRIBUTION OF SONOELASTOGRAPHY IN DIAGNOSIS OF POLYCYSTIC OVARY SYNDROME Çıracı S. 1, Tan S. 2, Keskin H. 3, Şirin Özcan A. 1, Ateş Ö. 1, Akçay Y. 1, Arslan H. 1 Ankara Atatürk Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 1 Bursa Şevket Yılmaz Eğitim ve Araştırma Hastanesi Radiology Bursa-Turkey 2 Ankara Atatürk Eğitim ve Araştırma Hastanesi Obstetrics and Gynecology Ankara-Turkey 3

Objective: In this study, we aimed to determine elasticity features of the ovarian stroma in women with polycystic ovary syndrome (PCOS) and establish diagnostic value of sonoelastography. Besides, we investigated correlation of elasticity values with clinical,hormonal and other sonographic parameters.

Materials and Methods: Bilateral ovarian stroma of PCOS (n=48) and control (n=48) group were assessed by using ultrasound (US) device capable of sonoelastography and 6.5 MHz vaginal probe. The volume and follicle count of each ovary were recorded. Strain ratio was calculated by comparing ovarian stroma with fallopian tube adjacent to the ovary. The average of 6 measurements obtained from each ovary were used. Strain ratio betweeen PCOS and control group was compared.Elasticity patern was constituted for each ovary. AURC (area under ROC curve) , optimal cut off , sensitivity and spesificity values for strain ratio were determined by plotting ROC curve. Correlations between strain ratio and body mass index, ferriman gallwey score, hormone levels, insulin resistance index and sonographics parameters were assessed.

Results: Elasticity patterns and strain rates were revealed significant difference between the two groups (P<0.01). ROC curve analysis indicated that the optimal cutoff point for strain ratio was 3.8 with an area under the ROC curve (AURC) of 0.888, a sensitivity of % 87.5 and specificity of % 85.4.In PCOS group, there was positive correlation between strain ratio and HOMA index.

Conclucions: Sonoelastography of the ovarian stroma may contribute to the diagnosis of PCOS and help to better understanding of the pathophysiology of this sydrome.

119 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS8.07 - REAL TIME ELASTOSONOGRAPHIC EVALUATION OF RENAL TRANSPLANTS IN CORRELATION WITH CLINICAL PROGNOSTIC PARAMETERS: PRELIMINARY RESULTS Gunes Tatar I. 1, Teber A. 2, Ogur T. 3, Kurt A. 1, Hekimoglu B. 1 Diskapi Yildirim Beyazit Research Hospital Radiology Ankara-Turkey 1 Yildirim Beyazit University Ataturk Research Hospital Radiology Ankara-Turkey 2 Golbası Hospital Radiology Ankara-Turkey 3

Objective: The aim of the study was to evaluate the the reliability of cortical elasticity (CE) measurement of renal transplants (RT) by using real time elastosonography (RTE) in correlation with clinical prognostic parameters.

Method: 28 renal transplant recipients ( 10 women, 18 men) (mean age, 37 years; age range, 23-65 years) underwent RTE. CE were measured in the upper poles, middle segments and lower poles of RT by using both linear and convex probes. Donor age above 50 years old, post transplantation time over 60 months and blood creatinin level above 1.5 mg/dl were defined as poor prognostic parameters. Mann Whitney-U, independent sample T-test and Kruskal Wallis methods were used for statistical analysis.

Results: In the group with blood creatinin level above 1.5 mg/dl CE measurements were higher in the middle segments and lower poles with convex probe and in the middle segment with linear probe (p:0.026, 0.007, 0.001 respectively).

Conclusion: High CE measurements of the middle segments were associated with high blood creatinin levels by using both linear and convex probes. The results might suggest that inflammatory and fibrotic processes start from the middle segments of the RT but the results need to be tested in larger series and correlated with biopsy.

SS8.08 - REAL-TIME ELASTOGRAPHY IN DIAGNOSTICS OF UROLOGY DISEASE O.B.Zhukov, A.V.Sivkov, N.G. Keshishev, A.V.Korjakin, A.A.Sinjagin FSBI “Scientific and Research Institute of Urology”

Introduction: Real-time elastography (RTE) is widely used in diagnostics of urology disease during last 6 years. It allows assessing degree of fibrosis and differentiating tumors of urinary system organs, scrotum and testicles.

Materials and methods: Ultrasound system Hitachi HI Vision Ascendus was on clinical approbation in FGBU… During this period it were made 140 ultrasound examinations of genito-urinary organs (34 of them were prostate examinations with RTE and 6 of them were scrotum&testicles examinations with 4D RTE). Also it was made 8 transrectal biopsies of prostate with biplane transducer EUP-CC531 based on data from B-mode ultrasound examination, RTE and HISTOSCANNING™. It should be noted that image quality of the ultrasound system was extremely good in usual modes (B-mode, Color Doppler) and in 4D RTE mode too. Superficial organs were examined with high-frequency linear probe EUP-L75 (5-18mHz), which allows visualizing and definitely differentiating the smallest structure alterations of tunica albuginea and endothelium of penis vessels. Fine Flow mode was very useful for examinations of tumors, because it is very sensitive to low-speed blood flow and allows visualizing tumor blood vessels with very high accuracy and quality. Biplane scanning with biplane endocavity transducer EUP-CC531 combined with RTE was especially in demand. We made 8 prostate biopsies from target points under control of this transducer, based on data of RTE and HISTOSCANNING™. 3 of that patients had previously revealed biochemical and MRI signs of prostate tumor relapse after prostatectomy, 2 were sent for the biopsy because of PSA increasing after brachytherapy, 1 - because of MRI signs of relapse after radical radiotherapy and 2 patients - because of PSA increasing after TUR in 3 and 5 years.

Results: Prostate biopsy performed with using of RTE from “target” zones revealed that 4 patients (50%) have prostate cancer, and 1 of them couldn’t be diagnosed after 2 standard prostate biopsies.

Conclusions: Real-time elastography allows settling lots of diagnostic and practical questions. It allows to except relapse of prostate cancer, improves visualization of tumors, which could be invisible in standard scanning modes and makes it possible to take material for morphological verification from the very suspicious zones. This method allows assessing size and stage of tumor for certain. And real-time virtual sonography, which allows combining MRI images with real-time elastography and other modern ultrasound technologies, creates perspective for future investigations.

www.esur2013.org 120 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Scientific Session 9 : Miscellaneous - I

SS9.01 - THE ROLE OF DIFFUSION WEIGHTED MRI FOR EVALUATION PERIANAL FISTULAE Sharifov R. 1, Cheikh Ahmad I. 1, Serter A. 1, Yetis H. 1, Kocakoç E. 1 Bezmialem Vakif University Radiology Istanbul-Turkey 1

Objective: To assess the value of diffusion-weighted magnetic resonance (MR) imaging (DWI) for evaluation of anal fistulae to compare with conventional MRI.

Methods: Thirty-seven patients (mean age, 40±20 years) with 55 anal fistulae were included. The protocol consisted of fat-suppressed T2-weighted fast spin echo (FS-T2W), single-shot echo-planar DWI (b factors 50, 400 and 800 s/mm2), and fat-suppressed contrast-enhanced T1-weighted gradient echo (FS-CE-T1W- GRE) sequences. Four-point scale was used for scoring: 1: probably not a fistula; 2: uncertain; 3: possible fistula; and 4: definite fistula. All cases were evaluated in three group; first DWI only, second DWI + FS-T2W, and third DWI + FS-CE-T1W-GRE by two experienced radiologists who were blinded to the diagnosis of the lesions in three different sessions. The Wilcoxon and McNemar tests were used for multiple comparisons of sensitivities.

Results: Fifty-three (96.3%) fistulae were detected on DWI, and 52(94.5%) on DWI + FS-T2W images, and 55(100%) were detected on DWI and contrast-enhanced images. There was no statistically significant difference between three groups for detecting presence of fistulae according to confidence score (P > 0.05). The number and anatomical location of perianal fistulae were as: intersphincteric(n=20), transphincteric(n=23), suprasphincteric(n=5), extrasphincteric(n=7).

Conclusion: Diffusion-weighted MRI is a useful technique and may be an alternative technique to conventional MR imaging for evaluation of anal fistulae, especially in patients with risk factors for contrast agents.

SS9.02 - NSSAFE STUDY: OBSERVATIONAL STUDY ON THE INCIDENCE OF NEPHROGENIC SYSTEMIC FIBROSIS IN RENAL IMPAIRED PATIENTS FOLLOWING GADOTERIC ACID ADMINISTRATION Maes B. 1 Heilig Hartziekenhuis Nephrology Roeselare-Belgium 1

Objective: To prospectively estimate the incidence of NSF in patients with moderate to severe renal impairment after administration of gadoteric acid. Methods: An ongoing worldwide post-marketing study (PMS) is conducted to collect safety data in 1,000 patients (adults and children) with moderate to severe and end stage renal impairment, scheduled to undergo a routine contrast-enhanced magnetic resonance (MR) imaging using gadoteric acid (Dotarem®). For each patient, risk factors at inclusion, indications for MR imaging, and occurrence of adverse events are recorded. Three follow up visits (between 3 months and 27 months after MRI) are performed in order to detect any suspicion or occurrence of NSF.

Results: As of January 18, 2013, the cut-off date for the interim safety analysis, this ongoing PMS included data on 232 patients (mean age: 70.2 years (range: 21-92); male: 62.5%). The mean eGFR was 36.5 ±16.1 ml/min/1.73m2 (range: 4.0-59.1) including 64.2% of moderate, 18.5% of severe, 14.2% of end stage renal insufficiency and 2.6% of kidney transplanted patients. CNS MR examinations accounted for nearly 25%. The first follow-up visit was done for 67 patients (29%) and no NSF occurred. Only 1 patient (0.4%) had two serious adverse events not related to gadoteric acid.

Conclusion: This interim safety analysis already confirms the very good safety profile of gadoteric acid in renal impaired patients.

121 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS9.03 - THE VALUE OF DIFFUSION-WEIGHTED IMAGING IN ENDOMETRIOTIC CYSTS Bekin Sarıkaya P. 1, Tarhan N. 1, Ayhan A. 2 Başkent University Hospital Department of Radiology Ankara-Turkey 1 Başkent University Hospital Department of gynecology and obstetrics Ankara-Turkey 2

Purpose:Diffusion-weighted (DW) imaging has recently been in use in the diagnosis of malignant lesions. The aim of this study is to show the signal changes relationship between DW images and T1-and T2- weighted images, and to determine the value of DWI in endometriotic cyst content difference.

Materials and Methods: This study included 37 patients aged between 22-47 with a total of 50 endometriotic cysts diagnosed clinically or with MRI. MRI was performed at 1.5T MR unit (Avanto, Siemens). T1W, T2W and DW axial MR images were analyzed for signal changes. Diffusion imaging with b = 0, 500 and 1000 values were obtained. On T1 and T2 weighted images, the cyst content’s intensity was compared to skeletal muscle and grouped as iso-hypointense, minimally hyperintense and hyperintense. Diffusion restriction was evaluated and ADC measurements were done for each component. Spearman’s correlation analysis and Mann-Whitney-U tests were used for statistical analysis.

Results: There was statistically significant correlation between DW, T2W images and ADC values (p <0.05). There was no significant correlation between T1W images and others. Mean ADC value of T2-hypointense cysts was 0.76 x10-3mm2/s, whereas the T2-hyperintense cysts was 2.45 x10-3mm2/s.

Conclusion: T2-hypointense endometriotic cysts which have higher iron content shows diffusion restriction and low ADC values. T2W and DW imaging may help assess the content of endometriotic cysts. In these patients it should be kept in mind that low ADC values may overlap with malignancy and evaluation should be done accordingly.

SS9.04 - SERUM CREATININE MEASUREMENTS: EVALUATION OF A QUESTIONNAIRE ACCORDING TO THE ESUR GUIDELINES. Zähringer C. 1, Potthast S. 2, Tyndall A. 1, Bongartz G. 1, Hohmann J. 1 University of Basel Hospital Clinic of Radiology & Nuclear Medicine Basel-Switzerland 1 University of Basel Hospital Department of Radiology Basel-Switzerland 2

Objective: The European Society of Urogenital Radiology propose measurements of serum creatinine levels in patients undergoing contrast-enhanced studies with a high probability of reduced renal function and therefore with a higher risk of CIN or NSF. The aim of this study was to determine whether the recommended questionnaire is able to correctly identify these patients.

Method: The questionnaire was applied to 1389 consecutive patients (f=725, m=654) before contrast administration for CT or MRI examination. Serum creatinine (SCr) measurements and calculation of estimated glomerular filtration rate (eGFR) values were performed when one or more answers concerning previous renal disease, known renal disease in relatives, history of diabetes, proteinuria, hypertension, gout and analgesic medication were positive. Statistical evaluation of 1308 patients with complete datasets was done using the Fisher test. Dependency between individual positive answers and the age of the patients was also evaluated.

Results: 499 patients gave one or more positive answers. Of these, only 68/71 patients had an elevated SCr level (f<96 µmol/l; m<110 µmol/l)/reduced eGFR value (<60 ml/min/1.73 m2). Only the question concerning previous renal disease showed a significant relation to an elevated SCr level (p=0.0011). All other questions did not present any significant correlation to the presence/absence of chronic kidney disease stage III and above, whereas patient age above 70 years demonstrated a high correlation (p<0.0001).

Conclusion: We propose to reduce the questionnaire to the single question on previous renal disease and to consider an a priori SCr measurement for all patients >70 years.

www.esur2013.org 122 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

SS9.05 - COMPUTED TOMOGRAPHY STAGING OF BLADDER CANCER : WHAT ARE THE CHEST FINDINGS? Shareef T. 1, Salim F. 1, Kennish S. 1 Royal Hallamshire Hospital Imaging Department Sheffield-United Kingdom 1

Objective: To analyse the chest CT findings in patients with new diagnosis of bladder cancer.

Method: Patients with new diagnosis of bladder cancer; proven by either histology or by cystoscopy over a 20 month period between July 2011 and March 2013 were retrospectively identified from uro-oncology MDT database. All patients had staging CT of the chest, abdomen and pelvis as part of their staging investigations. The incidence of pulmonary metastasis and any other significant chest abnormality was recorded.

Results: 152 patients with newly diagnosed bladder cancer underwent staging CT. 128 patients (84%) had normal CT chest appearances. 21 patients (13.8%) had indeterminate lung nodules. 2 patients (1.3%) had lung nodules highly suspicious for lung pulmonary metastases. One patient (0.6%) had a synchronous primary lung tumour.

One of the two patients with metastatic pulmonary disease had grade three poorly differentiated transitional cell carcinoma. The second patient did not have histology as diagnosis was made on cystoscopy.

Conclusion: In this study only 1.3% had appearances highly suspicious for lung metastases. 13.8 % had indeterminate lung nodules which required follow up. CT chest can be a useful part of staging investigation as it provides a baseline for post treatment follow up imaging.

SS9.06 - EVALUATION OF THE LEFT RENAL VEIN VARIATIONS, THE INFERIOR VENA CAVA VARIATIONS AND RENAL ANOMALIES BY MAGNETIC RESONANCE IMAGING Ayaz U. 1, Dilli A. 2, Karacan K. 3, Karabacak O. 4, Hekimoglu B. 2 Mersin Kadın Doğum ve Çocuk Hastalıkları Hastanesi Radiology Mersin-Turkey 1 Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 2 Cumhuriyet Üniversitesi Tıp Fakültesi Anatomy Sivas-Turkey 3 Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Urology Ankara-Turkey 4

Objective: This study aims to determine the types and prevalence rates of the renal congenital anomalies, variations of the vena cava inferior, and variations of left renal vein detected during MR evaluation for intervertebral disc disease.

Method: A prospective study was conducted in 3000 consecutive patients on lumbar MRI. Findings were classified as congenital anomalies and anatomical variations. We used the PACS to evaluate the images in our institute.

Results: The most common abnormalities of right kidney were renal agenesis and ectopic kidney and seen in 2% of the cases. The most common abnormality of the left kidney was the malrotation seen in 0.1% of the cases. Renal anomalies detected 1.1% in female, and 0.6 in male patients, prevalence was similar for genders (p=0.20). The most common variation of the left renal vein was retroaortic left renal vein and seen in 2.1% of the cases.VCI variations were the left VCI (n = 1) and double VCI (n = 1).

Conclusion: On MRI examinations of intervertebral discs, paying attention to extraspinal findings as renal congenital anomalies, left renal vein varations and vena cava inferior variations will give additional information to evaluate the frequency of variations and anomalies. The detection of renal anomalies, LRV and VCI variations will contribute to the overall clinical evaluation of patients and reduce the likelihood of complications in patients whom considered to undergo retroperitoneal surgery.

123 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY POSTER SESSIONS

Poster Session 1 - Women Genital System and Pelvic Imaging

P1-01 - MRI FEATURE OF SOLID CLEAR CELL CARCINOMA OF THE OVARY Takahama J. 1, Marugami A. 1, Marugami N. 1, Itoh T. 1, Kichikawa K. 1 Nara Medical University Radiology Kashihara-Japan 1

Aim:Ovarian clear cell carcinoma, usually consists of hemorrhagic cyst and solid mural nodules. Though this specific feature is useful for diagnosis, some of them can show almost solid without hemorrhagic cyst. The purpose of this study is to clarify the MRI feature of solid clear cell carcinoma of the ovary.

Materials and Method:We reviewed 5 patients histopathologically diagnosed as clear cell carcinoma(mean age 56, range47-64). We analyzed 6 lesions (One patient had bilateral tumors) about MR images retrospectively. The analyzed items are follows; 1. maximal diameter, 2. signal intensity (SI) on T1WI, T2WI and DWI, 3. central scar like high intensity region on T2WI, 4. trabecular low intensity area on T2WI, 5. the shape (round or lobular), the surface (regular or irregular), and 6. the concomitant hemorrhagic cyst.

Result:1. The mean of maximal diameter was 97±51mm(range 46-175). 2. SI on T1WI; (iso; 6)、SI on T2WI (high;4, iso-high;2)、SI on DWI (high;6). 3. The central scar like high intensity region on T2WI was observed in 3. 4. The trabecular low intensity region in 4 patients. 5. The shape was round in 4, lobular in 2, and surface was smooth in 6. 6. The concomitant hemorrhagic cyst was observed in only one patients.【conclusion】Solid clear cell carcinoma of the ovary rarely consists of hemorrhagic endometrial cyst. On T2WI, the central scar like high intensity region and trabecular low intensity region on T2WI is characteristic findings of the solid clear cell carcinoma.

P1-02 - DYNAMIC CONTRAST ENHANCED MRI OF THE UTERINE ENDOMETRIAL CARCINOMA AT 3T; THE VALUE OF SUBENDOMETRIAL ENHANCEMENT Takahama J. 1, Wongladarom S. 2, Marugami A. 1, Imanaka S. 3, Kichikawa K. 1 Nara Medical University Radiology Kashihara-Japan 1 Chiang Mai University Radiology Chiang Mai-Thailand 2 Nara Medical University Gynecology Kashihara-Japan 3

Purpose:The objective of our study was to evaluate the subendometrial enhancement (SEE) of dynamic contrast enhancement at 3-T MRI in determining the depth of myometrial infiltration in patients with endometrial cancer.

Materials and Methods: Forty-four patients with histopathologically proven endometrial carcinoma underwent preoperative 3-T MRI. The following sequences were performed for dynamic study: axial 3D T1 inversion recovery gradient-echo after contrast administration in every 30 seconds. All patients underwent a hysterectomy after MR examination. The MRI findings were compared with histopathology results. ROI was also measured at tumor, SEE, and myometrium for each phase and CNR was calculated.

Results:Subendometrial enhancement was observed in 54.5% (24/44) respectively. The thickness of the SEE was over 2mm in 91% (22/24). For the detection of peri-tumoral enhancement was 79% (19/24). Of 19 patients, 11 patients had 1/2 over myometrial invasion. In these cases, irregular peritumoral enhancement can be distinguished from SEE. The CNR of endometrial carcinoma/ SEE, SEE/myometrium was maximum at early phase (60 sec after the administration).

Conclusion:In evaluating the depth of myometrial infiltration in patients with endometrial cancer, SEE disruption was reported as the sign of myometrial invasion. For the higher contrast dynamic contrast 3D gradient-echo sequence at 3-T MRI showed both SEE and peri-tumoral enhancement. To diagnose the myometrial infiltration of the carcinoma, the SEE and peri-tumoral enhancement should be considered as the depth of myometrial invasion instead of the disruption of the SEE.

www.esur2013.org 124 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-03 - UNDIFFERENTIATED ENDOCERVICAL CARCINOMA A CASE REPORT. Lim K. 1, Seo Y. 1, Yun E. 1, Yoon D. 1, Choi C. 1, Bae S. 1 Kangdong Seong-Sim Hospital, Hallym University College of Medicine Radiology Seoul-Korea, South 1

A 54-year old woman was admitted to our hospital with the chief complaint of abdomen and back pain for 3 days. She had menorrhagia, but no vaginal bleeding. Transvaginal US showed large echoic mass. Pelvis CT showed ill-defined large heterogeneous low attenuation mass with exophytic growth in uterine cavity and myometrium. Multiple enlarged lymph nodes with necrosis were showed in bilateral para-aortic areas and iliac chains. Also, large amount of ascites and peritoneal infiltrations with thickening in left abdomen were showed. MRI demonstrated multilobulated high signal intensity mass on T2-weighted images and iso signal intensity on T1- weighted images. Contrast enhanced T1-weighted subtraction images showed strong enhancement with internal necrosis. Radical hysterectomy and bilateral adnexectomy with pelvic lymph node dissection was done. Pathology revealed undifferentiated endocervical sarcoma, most probably.

P1-04 - IMAGING FEATURES OF INTRAUTERINE DEVICES DIFFERENT TYPES DIFFERENT LOCATIONS DIFFERENT IMAGING MODALITIES Berkenblit R. 1, Frank S. 1 Montefiore Medical Center Radiology Bronx-United States 1

Objective: Intrauterine devices (IUDs) are a common form of contraception. This poster will make the reader aware of the imaging appearance of various IUDs as well as demonstrate the appearance of IUDs that are in proper location and those that are in inadequate locations.

Methods: Multiple cases of IUDs being in proper location as well as being improperly situated are presented. These findings are shown on multiple imaging modalities including plain film, ultrasound (U/S), CT and MRI. In addition, the value of 3D ultrasound (3D US) in evaluating IUDs is demonstrated.

Results: Normally situated IUDs as well as those that are too low in the uterus, inverted in the uterus, external to the uterus and those that have become infected are demonstrated with various imaging modalities. In addition, the appearance of various types of IUDs is demonstrated in this poster.

Conclusion: As IUDs are commonly used, the radiologist must be aware of their normal appearance as well as the appearance of abnormally situated IUDs on various imaging modalities.

P1-05 - ACCURACY OF MAGNETIC RESONANCE IMAGING AND DIFFUSION WEIGHTED IN ESTIMATING DEGREE OF MYOMETRIAL INVASION IN CASES OF ENDOMETRIUM CANCER Afifi-Hafez. A. 1, Keshk-Mohamad . S. 1, Alsharkawy Y. 1 Faculty of Medicine Radiology Alexandria-Egypt 1

Objectives: Depth of myometrial invasion is the most important morphologic prognostic factor, as superficial myometrial invasion (<50%, stage IA) is treated with simple hysterectomy, whereas deep invasion (≥50%, stage IB) also requires lymph-adenctomy because of an increased incidence of nodal metastases. The aim of this work is to assess the diagnostic accuracy of magnetic resonance imaging and Diffusion weighted MRI for evaluation of myometrial invasion in patients with endometrial cancer.

Methods: Twenty four cases of endometrial cancer patients surveyed for the degree of myometrial invasion using closed magnet 1.5 tesla MRI. Conventional T1, T2 and post dynamic contrast enhancement T1 weighted images. Diffusion weighted images using different b values were used (0, 500, 1000) followed with ADC maps were reconstructed on the workstation for qualitative and quantitative assessment of DWI images. Postoperative histopathological correlation with imaging findings was done.

Results: MRI had an accuracy of 95.8%, 23 patients out of 24 had histologically proven invasion that correlated with MRI.The sensitivity, specificity, positive and negative predictive values for MRI were 80, 100, 100, 90% for superficial and 100, 100, 100, 100% for deep myometrial infiltration respectively.

Conclusion:All MR imaging modalities are useful in assessing the depth of myometrial invasion in endometrial cancer and play a key role in preoperative evaluation allowing accurate staging of the patient and hence right selection

125 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-06 - THE DIAGNOSTIC ACCURACY OF MDCT IN THE EVALUATION OF OVARIAN TORSION COMPARED WITH MISDIAGNOSED CASES Kim Y. 1, Ku Y. 2, Lee S. 3 Inje University, Ilsan Paik Hospital Radiology Goyang-Korea, South 1 Catholic University Medical College, Uijeongbu St. Mary Radiology Uijeongbu-Korea, South 2 Catholic University Medical College, Uijeongbu St. Mary Radiolgy Uijeongbu-Korea, South 3

Objectives: To identify the helpful MDCT findings for the correct pre-operative diagnosis of ovarian torsion. To know the cause of misdiagnosis of ovarian torsion with the cases surgically confirmed as ovarian torsion.

Method: During the period from 2004. 1. 1 to 2012. 12. 31, 67 cases of MDCT among the 105 cases surgically confirmed as ovarian torsion (at our institution) were retrospectively reviewed. Sixty-seven patients were divided into group A (n=42, correctly diagnosed as ovarian torsion) and group B (n=25, in-correct pre-diagnosis patients). We evaluated these cases with already well-known CT imaging features of ovarian torsion such as (1) enlarged ovary, (2) associated mass, (3) asymmetrical cystic wall thickening, (4) tubal thickening or twisted torsion knot, (5) ascites, and (6) hemorrhage, and compared their frequencies.

Results: Group A (42 correct pre-diagnosis patients; 63%) and Group B (25 in-correct pre-diagnosis patients; 37%) are reviewed. The twisted torsion knot found to give high reliability. The enlarged ovary, asymmetrical cystic wall thickening show important factor. The ruptured ovarian torsion or pelvic hematoma are often a factor that lead to mis-diagnosis.

Conclusion :The MDCT features of ovarian torsion are very helpful tool for diagnosis and the trial of searching the twisted knot throughout the multiplanar image is very critical for the correct diagnosis of ovarian torsion.

P1-07 - DIAGNOSTIC PERFORMANCE OF 3T MRI IN PREOPERATIVE STAGING OF UTERINE CERVICAL CARCINOMA İnan N. 1, Doğan D. 1, Sarisoy H. 1, Akansel G. 1, Yücesoy İ. 2, Müezzinoğlu B. 3 Kocaeli University Radiology Kocaeli-Turkey 1 Kocaeli University Obstetrics and Gynaecology Kocaeli-Turkey 2 Kocaeli University Pathology Kocaeli-Turkey 3

Objective: To evaluate the diagnostic accuracy of sequences obtained with 3T MRI in staging of cervical carcinoma.

Method: Twenty-two women with histologic diagnosis of cervical carcinoma were included and all patients were examined by 3T MRI. Precontrast axial,coronal, sagittal oblique T2-W SS-TSE and axial oblique diffusion weighted images (DWI) were performed using a breath-hold SS-EPI-TSE sequence . ADC maps were reconstracted from b 0 and 1000 sec/mm². Subsequently, nine dynamic series of T1-W THRIVE (T1 High Resolution Isotropic Volume Examination) images were obtained (0-180 sec) followed by a T1-W THRIVE sequence in the late phase (5th min). For detection of parametrial infiltration; sensitivity, specificity, PPV, and NPV were calculated on T2-W SSh-TSE, postcontrast early arterial phase (25th sec) and late phase (5th min) T1-W THRIVE SPAIR, and DWI.

Results: There was significant agreement between MRI and surgicopathologic findings in the assessment of staging. For parametrial infiltration; DWI and late phase contrast enhanced images obtained higher diagnostic accuracy than those of the others The MRE of carcinomas were significantly lower than those of the normal cervical tissues. This quantitative analysis showed a significant improvement in tumor versus normal cervical tissues contrast during the late phase compared with the arterial phase. On DWI, the mean ADC value of tumor and normal cervical tissues were 0,78±0,19x10-³ and 1,25±0,48x10-³ mm²/sec, respectively. Conclusion: As the 3T MRI scanner allows high resolution images, accurate assessment of parametrial infiltration can bedone especially with DWI and postcontrast late phase

www.esur2013.org 126 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-08 - IMAGING FEATURES OF OVARIAN CYSTIC LESIONS WITH EMPHASIS ON DIFFERENTIAL DIAGNOSIS Park S. 1, Lee J. 1, Park H. 1 Chung-Ang University Hospital Radiology Seoul-Korea, South 1

Ovarian cystic lesions are broad spectrum from physiologic, benign functional cyst to the malignant cystadenocarcinoma. Treatment of choice may often be problematic, especially in young reproductive women. Precise knowledge of clinical and imaging features, especially MR imaging is crucial in establishing an accurate diagnosis and determining treatment. The purpose of this presentation is to discuss MR strategies for identification and characterization of ovarian cystic lesions. In this presentation, we describe imaging features of the tumorous (cystic neoplasm including cystadenofibroma, mature cystic teratoma, struma ovarii and malignant transformation arising from endometriosis) and non-tumorous (functional ovarian cyst including follicular cyst, corpus luteal cyst and theca luteal cyst, ovarian hyperstimulation syndrome, endometriosis, hemorrhagic cyst, paraovarian cyst, peritoneal inclusion cyst, tuboovarian abscess, polycystic ovarian syndrome, and massive ovarian edema) ovarian cystic lesions. We correlate imaging features with clinical and pathologic features. We also describe specific considerations such as daughter cyst sign and stained glass appearance. We list limitations and pitfalls. Precise knowledge of clinical and imaging features, especially MR imaging is crucial in establishing an accurate diagnosis and determining treatment. Knowledge of key features of ovarian cystic lesions provides the criteria for making diagnosis or substantially narrowing the differential diagnosis. Familiarity with the clinical setting and imaging features of various ovarian cystic lesions as depicted with US, CT, and MR will facilitate prompt and accurate diagnosis and treatment.

P1-09 - ENDOMETRIOID OVARIAN ADENOCARCINOMA ASSOCIATED WITH ESTROGEN PRODUCTION A CASE REPORT Tsuda M. 1, Ishii K. 1, Shibuya R. 2, Naganuma H. 2 Sendai Cyty Hospital Radiology Sendai-Japan 1 Sendai Cyty Hospital Pathology Sendai-Japan 2

Objectives: To report a unusual case of endometrioid ovarian adenocarcinoma associated with estrogen production.

Method: A 79-year-old woman was admitted to our hospital complaining of scant atypical genital bleeding, mammary tenderness and pain. The level of serum estradiol was as high as 33.9 pg/ml. The endometrial tissue showed hyperplastic changes. On MRI, the tumor appeared as a multi-locular cystic mass with solid components. The solid portion of this tumor also showed very low intensity with multiple very high intense tiny cysts on T2-weighted images. After the administration of intravenous contrast medium, the solid components showed intense enhancement, and small cystic areas scattered within them were better displayed.

Results: Laparotomy showed that the right ovarian tumor had a diameter of 7 cm. The tumor was not adhesive to the surrounding organs. Neither macroscopic dissemination nor abnormal ascites were noted in the peritoneal cavity. Bilateral salpingo-oophorectomy were performed. The pathological diagnosis was endometrioid adenocarcinoma of right ovary. The cytology of peritoneal washing fluid was negative. Her serum estradiol level has remained undetectable (<5pg/mL). Her mammary tenderness, pain and endometrial hyperplasia disappeared soon after surgery.

Conclusion: In ovarian tumors most estrogen-producing tumors are sex-cord stromal tumors such as granulosa cell tumors and thecomas. To the best of our knowledge, ovarian surface epithelial cancers producing estrogen have been reported, in which the serum level was elevated and estrogen-related manifestations were present, however, the frequency of endometrioid adenocarcinoma with functioning stroma is very low. Here is a rare case with the patient’s clinical course, MR imaging and pathologic findings.

127 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-10 - BENIGN CYSTIC OVARIAN TERATOMA WITH A FISTULA INTO THE SMALL BOWEL Das C. 1, Artas H. 1, Artas G. 2, Kılıcarslan A. 2, Ayten R. 3, Ozercan I. 2 Firat University, Faculty of Medicine Department of Radiology Elazig-Turkey 1 Firat University, Faculty of Medicine Department of Pathology Elazig-Turkey 2 Firat University, Faculty of Medicine Department of General Surgery Elazig-Turkey 3

Objective: Ovarian dermoid cysts are one of the most common benign neoplasms in women. Intra- peritoneal rupture or perforation into adjacent abdominal viscera is a rare complication of benign cystic teratoma. We present a case of a benign ovarian dermoid cyst complicated with ileal fistula.

Method: A 62-year-old woman admitted to the emergency department because of diffuse abdominal pain, nause, and vomiting. ResultsAbdominal X-ray showed dilated loops of small bowel with air-fluid levels. Abdominopelvic computed tomography scan showed a complex cystic mass with containing air, calcifications and peripheral fat in the right ovary. On laparoscopy, a mass lesion originating from the right ovary was seen with contiguous with the small intestine. At this point, the decision was made to proceed to laparotomy. The cystic mass lesion also had formed a fistula into the small bowel, partial obstructing the lumen The affected segment of small bowel and cystic mass lesions were resected, and a side-to-side reanastomosis was performed. A right salpingo- oophorectomy also was performed. The left adnexa appeared normal. The final pathology returned mature cystic teratoma of the right ovary fistulized into the lumen of the small bowel.

Conclusion:Factors such as torsion, infection, trauma, and chronic pressure during labor, spontaneous rupture of the dermoid cyst resulting in leakage of fluid could be the cause of fistula formation.

P1-11 - EFFICACY OF DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING IN DIAGNOSIS AND STAGING OF THE ENDOMETRIAL TUMORS Keçeci İ. 1 Radiology Samsun Eğitim Ve Araştırma Hastanesi Samsun-Turkey 1

Purpose:Our aim is firstly to evaluate the efficacy of DWI in the differentiation of benign and malignant lesions of the endometrial cavity and the determination of tumor grade,and secondly,to determine the contribution of the DWI to the diagnosis,in order to detect the depth of myometrial invasion of malignant lesions.

Materials and Methods:A total of 56 patients detected lesions in the endometrial cavity were included in the study.The lesions were classified as benign or malignant according to the histopathological results and the mean ADC values were compared.For determining the depth of myometrial invasion of malignant lesions,T2W-DWI and DCET1WI were evaluated independently.According to the histopathological results,for each of the T2W-DWI and DCET1WI,diagnostic accuracy,sensitivity and specificity were calculated with 95%CI.

Results:The mean ADC values were for malignant lesions and benign lesions were 0.94±0.18x10–3mm2/s and 1.45±0.22x10–3mm2/s,respectively.When the threshold value of ADC was taken as 1.10x10-3 mm2/s,the sensitivity,specificity and AUC were calculated to be as 85.7%,92.8%,0.95,respectively.For endometrioid adenocarcinomas,according to the histological grading,in terms of the tumor grading,there was no difference for the mean ADC values between the groups.The diagnostic accuracy of MRI in determining the depth of myometrial invasion of malignant lesions was found for T2-DWI and DCET1WI as 87.1% and 76.9%,respectively.

Conclusion:DWI and ADC measurements have a high diagnostic accuracy in the determination of lesions detected in endometrial cavity as benign and malignant.The diagnostic efficacy of DWI assessed with T2Wimages for the evaluation ofthe depth of myometrial invasion of malignant lesions,is quite high,it would be useful entering of DWI tothe routine evaluation of the endometrial cavity lesions.

www.esur2013.org 128 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-12 - IMAGING FINDINGS OF GRANULAR CELL TUMOR OF VULVA Çoban G. 1, Tarhan N. 1, Özen Ö. 2, Ayhan A. 3 Baskent University Medical School Radiology Konya-Turkey 1 Baskent University Medical School Pathology Ankara-Turkey 2 Baskent University Medical School Obstetrics and Gynecology Ankara-Turkey 3

Granular cell tumors (GCT) are very uncommon tumors and were first described by Abrikossoff in 1926. They are small, painless, slow-growing subcutaneous nodules most commonly seen in the tongue and oral mucosa. 5-16% of the granular cell tumors have been reported in the vulva. In this case, we present the imaging findings of a 61-years-old female who had GCT of the vulva. On ultrasonography there was ill-defined, lobulated heterogeneous solid mass with central hypoechoic and peripheral slightly hyperechoic areas in vulvar subcutaneous fat. On MRI, the tumor was hypointense on T1 and T2-weighted images compared to fat tissue, isointense with muscles on T1-weighted images and slightly iso-hyperintense with muscles on T2-weighted images. Dynamic examination showed early diffuse enhancement more peripherally, which were also continuing on late phase images. On CT images, the tumor was isodense to adjacent muscles and showed minimal enhancement. There were no regional or distant metastasis and no lymphadenopathy. The tumor was treated by wide surgical excision and pathology was consistent with granular cell tumor. The patient has been followed for 8 months without local recurrence or any intra abdominal lesions. There are only a few cases in the literature that discussed the imaging findings of GCT occurred in the breast, inferior rectus muscle, the skull base, the respiratory tract and intradural extramedullary region of the spinal canal. Herein, we aimed to report and discuss the imaging findings of the GCT of the vulva.

P1-13 - ULTRASOUND FINDINGS OF ANTERIOR ABDOMINAL WALL SCAR ENDOMETRIOSIS CASE SERIES Üstüner E. 1, Üstüner I. 2, Düşünceli Atman E. 1, Uzun Ç. 1 Ankara University School of Medicine Radiology Ankara-Turkey 1 Recep Tayyip Erdoğan University School of Medicine Obstetrics and Gynecology Rize-Turkey 2

Object: Anterior abdominal wall scar endometriosis is a rare occurrence, often develop after cesarian sections due to tissue implantation. Herein we will discuss and review the ultrasound imaging findings of scar endometriosis in a case series with emphasis on the differential diagnosis.

Method: Retrospective analysis revealed 7 scar endometriosis cases in which 4 had stored ultrasound images and one had an additional MR study. Analysis also revealed two similar appearing cases which were later diagnosed as an adenocarcinoma metastasis to the rectus muscle and a fibromatosis. Stored US images of the adenocarcinoma metastasis were present.

Results: Scar endometriomas often develop 2-3 years after a cesarian section to women in their 3rd decades. Mass is a common symptom along with cyclic pain. Various US presentations of disease is present depending on the chronicity, bleeding and histology. The lesions may be solid or semisolid with cystic components. Fibrotic elements and bleeding may cause the lesion to appear heterogenous with acoustic attenuation while lesions barely undetectable are also encountered. Color Doppler imaging may reveal vascularization or even a feeding vessel. Surrounding tissue may become hyperechogenic due to reactive changes and edema. Blood elements in MR are quite suggestive. Suture granulomas, hernias, hematomas, lymphadenopathies, neuromas, lipomas, desmoids tumors, sarcomas and metastatic lesions may mimic scar endometriosis.

Conclusion: Imaging diagnosis of scar endometriosis is often possible when classical implantation site near the scar tissue, clinical history and imaging findings are combined.

129 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-14 - EFFICACY OF DIFFUSION-WEIGHTED MAGNETIC RESONANCE IMAGING IN DIAGNOSIS AND STAGING OF THE ENDOMETRIAL TUMORS Keçeci İ. 1, Nural M. 2, Danaci M. 2, Aslan K. 2, Kefeli M. 3, Tosun M. 4 Samsun Training & Research Hospital Radiology Samsun-Turkey 1 Ondokuz Mayis University, Faculty of Medicine Radiology Samsun-Turkey 2 Ondokuz Mayis University, Faculty of Medicine Pathology Samsun- Turkey 3 Ondokuz Mayis University, Faculty of Medicine Obstetrics and Gynecology Samsun-Turkey 4

Purpose: Primarily is to evaluate the efficacy of DWI in the differentiation of benign and malignant lesions of the endometrial cavity and the determination of tumor grade and secondarily to determine the contribution of the DWI to the diagnosis in order to detect the depth of myometrial invasion of malignant lesions.

Materials and methods: A total of 56 patients with endometrial cavity lesion were included in the study. The cutoff value of ADC for the differentiation of benign and malignant was determined by ROC analysis. Diagnostic accuracy, sensitivity and specificity for both T2WI-DWI and contrast-enhanced T1WI were calculated.

Results: The mean ADC values were for malignant and benign lesions were 0.94±0.18x10–3 and 1.45±0.22x10–3 mm2/s, respectively with significant differences between two groups (p<0.05. The sensitivity, specificity and AUC for discriminating malignant from benign lesions on using cutoff ADC values of 1.10x10- 3s/mm2 were 85.7%, 92.8%, 0.95, respectively. According to the histopathological tumor grading, there was no difference for the mean ADC values. The diagnostic accuracy of MRI in determining the depth of myometrial invasion of malignant lesions was found for T2WI-DWI and contrast-enhanced T1WI as 87.1% and 76.9%, respectively.

Conclusion: DWI has a high diagnostic accuracy in the determination of lesions in endometrial cavity as benign and malignant. The diagnostic efficacy of DWI assessed with T2WI for the evaluation of the depth of myometrial invasion of malignant lesions, is quite high, it would be useful entering of DWI to the routine evaluation of the endometrial cavity lesions.

P1-15 - MR IMAGING-BASED MORPHOLOGIC CLASSIFICATION SYSTEM FOR CYSTIC ADENXAL LESIONS TO GUIDE THE DIFFERENTIAL DIAGNOSIS Lee Y. 1 Kanguk Samsung Hospital Radiology Seoul-Korea, South 1

The imaging-based characterization of adnexal cystic lesions is necessary for appropriate patient management. Accurate characterization of the internal features of a cyst—including fluid, septa, and enhancing solid components—is important to guide the differential diagnosis, and magnetic resonance (MR) imaging is the optimal modality for depicting these features. We have suggested a simple MR imaging-based classification system for cystic adnexal lesions that is based on the morphologic features. Cystic lesions of the ovary may be divided as four morphologic categories: (a) Unilocular cysts, (b) Multilocular cysts, (c) Multiseptated cysts, and (d) Cysts with enhancing solid components. Although the majority of unilocular cysts are benign lesions which include functional cyst, cyst adenoma, mucinous cyst, endometrioma, inclusion cyst, para ovarian cyst, paratubal cyst, peritoneal inclusion cyst, cystic metastases are uncommon cause of unilocular cystic lesions. The multilocular cysts are mainly benign or inflammatory lesions which include endometrioma, hydrosalpinx, tubovarian abscess, chronic ectopic pregnancy. Most of the multiseptated cysts are benign or borderline cystic tumors. Most of the cystic lesions with solid components are malignant lesions, but some benign tumors have solid components mimicking malignant neoplasm. Unilocular cyst with solid component (clear cell carcinoma, yolk sac tumor, thecoma, decidualized endometrioma) : Multilocular cyst with solid component (cystadenocarcinoma, cystadenofibroma, struma ovarii): Multiseptated cyst with solid component (cystadenocarcinoma, cystadenoma, graulosa cell tumor, sclerosing stromal cell tumor, Krukenberg tumor from colon or appendix). Knowledge of the varied MR imaging appearances of adnexal cystic lesions may help radiologists achieve greater specificity in diagnostic reporting.

www.esur2013.org 130 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-16 - THE VALUE OF PREOPERATIVE MR IMAGING TO PREDICT ADHESIONS TO THE COLON IN PATIENTS WITH OVARIAN ENDOMETRIOMAS Lee Y. 1 Kangbuk Samsung Hospital Radiology Seoul-Korea, South 1

Purpose: To assess the value of preoperative MR imaging to predict colon adhesion in patients with ovarian endometriomas

Materials and Methods: Eighty-one patients who had undergone MRI examination for suspected endometriosis were retrospectively evaluated. We performed analysis of the morphologic characteristics of the endometrioma and the presence or absence of the findings related to ovarian endometriomas as signs of adhesions.

Results: Bilaterality was more frequently found in the adhesion group, No difference was found for the diameter of the largest cyst and the lump sum of the diameters of multiple cysts between the two groups. The maximum cyst wall thickness and cyst wall enhancement were also not different between the two groups. Among the ancillary findings, hypointense strands toward a bowel loop were significantly more frequent in the adhesion group. The findings of angulations of bowel loops, elevation of the vaginal fornix and the ‘kissing ovaries’ sign were more frequently found in the adhesion group.

Conclusion: Preoperative MRI seems to be useful tool to predict adhesions of the colon associated with ovarian endometriomas.

P1-17 - PELVIC FIBROMATOSIS PRESENTING AS AN ASYMPTOMATIC VAGINAL STUMP MASS. Rha S. 1, Oh S. 1, Byun J. 1 Seoul St. Mary’s Hospital, The Catholic University of Korea Radiology Seoul-Korea, South 1

A 64-year-old woman presented with incidentally found mass in the vaginal stump during the health examination. She underwent total hysterectomy for myoma uteri 15 years ago. MRI showed a 4 x 3 cm sized lobulated solid mass in the lower pelvic cavity between the vaginal stump and urinary bladder. The mass showed isointensity compared with muscle on T1-WI and heterogeneous low signal intensity on T2-WI. Following contrast enhancement, the mass showed strong contrast enhancement. Diffusion weighted images showed no significant diffusion restriction in the mass. Surgery revealed a focal solid mass in the vaginal stump with adhesive change to the bladder. On microscopic examination, the tumor consisted of elongated spindle-shaped (fibroblast-like) cells of uniform appearance surrounded by dense bands of collagen. The final pathologic diagnosis was intraabdominal fibromatosis (desmoids tumor).

P1-18 - YOLK SAC TUMOR OF ENDOMETRIUM ORIGINATED FROM AN ADENOMYOMA MRI FINDINGS Kılıc D. 1, Tarhan C. 1, Rahatlı S. 2, Haberal Reyhan N. 3, Altundag Ö. 2, Dursun P. 4, Ayhan A. 4 Başkent University Radiology Departmant Ankara-Turkey 1 Başkent University Medical Oncology Departmant Ankara-Turkey 2 Başkent University Pathology Departmant Ankara-Turkey 3 Başkent University Obstetric and Gynecology Departmant Ankara-Turkey 4

Aim:Yolk sac tumor (endodermal sinus tumor) is a rare ovarian neoplasm mostly seen in infants and adolescents. Yolk sac tumor’s extragonadal involvement is very rare and only 10 cases of primary yolk sac tumor of the endometrium were reported in the literature. In this case, MRI findings of endometrial primary yolk sac tumor originating from an adenomyoma are presented.

Case: 57-year-old woman who had complaints of nausea, vomitting, abdominal pain, and weight loss for 2 months was admitted to our hospital. She had high Ca-125 and α-FP levels, molar pregnancy history and pelvic MRI was performed.

Findings: Pelvic MRI showed an infiltrative mass of uterine body with necrotic and hemorrhagic components, with diffuse enlargement of uterus. The mass was mainly hypointense on T2-weighted images, showing

131 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY diffuse contrast enhancement except the necrotic component. Both ovaries were enlarged and thought as infiltrated by the tumor. There were also lymph node enlargement and bone metastasis detected on MRI. With these findings, uterine sarcoma and germ cell tumors were the first differential diagnoses. Pathology was consistent with yolk sac tumor of the endometrium originated from an adenomyoma. The patient started chemotherapy and during the second cycle she died of septic shock.

Conclusion: Serum α-FP levels are important tumor markers.Since endometrial origin of primary yolk sac tumor is rarely monitored, MR imaging findings are presented here. When evaluating uterine masses with necrotic components, the high values of α-FP should raise the possibility of yolk sac tumor in the differential diagnosis.

P1-19 - APPARENT DIFFUSION COEFFICIENT VALUE IN DIAGNOSIS AND EVALUATION OF CERVICAL CANCER Koc Z. 1, Cakir Pekoz B. 1, Erbay G. 1, Onal C. 2 Baskent University Faculty of Medicine Radiology ANKARA-Turkey 1 Baskent University Faculty of Medicine Radiation Oncology ANKARA-Turkey 2

Objective: To explore the efficacy of apparent diffusion coefficient (ADC) measurement in the diagnosis and evaluation of cervical cancer.

Method: Consecutive 46 patients and 21 control subjects underwent diffusion-weighted imaging (DWI) in addition to routine MR imaging at 1.5-T MRI scanner before therapy Single-shot echoplanar imaging (SH- EPI) DWI with four b values and one ADC map was obtained using b0, 200, 600, 1000 s/mm2. Mean ADC, minimum ADC, and invasive region ADC of tumor were measured.

Results: The ADCs of cervical cancer were significantly lower than those of normal cervix (0.74±012 x10- 3mm2/s vs. 1.19±0.14 x10-3mm2/s; p<0.001). There was a significant correlation between the ADCs of invasion region and minimum ADCs (Pearson correlation coef. 0.61, p<0.001). Significant difference was not found between the ADCs of squamous cell carcinoma (n=40) and adenocarcinoma (n=6) (0.76±0.15 x10- 3mm2/s vs. 0.70±0.14 x10-3mm2/s; p=0.4).

Conclusion: In DWI, ADC measurement was reliable for differentiation between cervical cancer and normal cervix with high diagnostic accuracy. The invasion regions of tumors have lower ADC values.

P1-20 - A CASE OF IMPERFORATED HYMEN IN A REGULARLY MENSTRUATING GIRL Atci N. 1, Dolapcioglu K. 2, Güler Okyay A. 2, Karateke A. 2, Kartal İ. 1, Bayarogullari H. 1 Mustafa Kemal University Radiology Hatay -Turkey 1 Mustafa Kemal University Obstetrics and Gynecology Hatay-Turkey 2

Uterus didelphys, a mullerian anomaly, coincidental with renal agenesis an unilateral imperforated hymen is extremely rare. It mostly presents with cyclical abdominal pain, dysmenorrhea or the feeling of abdominal mass. In this report, a case of uterus didelphys regularly menstruating from the left side and suffering for cyclical abdominal pain due to hematocolpos and hematometra because of imperforated hymen on the right side was presented.

13-year-old girl was admitted to the emergency service with the symptoms of dismenorea, and abdominal mass. Her medical history revealed cronical abdominal pain and right renal agenesis. Labratory tests were normal. Ultrasonographic examination revealed a tubular cystic mass measuring 4x8 cm, extending from right lower abdominal quadrant to end of the midpelvis. Magnetic resonance imaging demostrated that uterin didelphys and duplicated vagina with right hematocolpos and hematometra. Imperforated hymen on the right hemivagina was confirmed by pelvic inspection. We performed an incision on longitudinal unilateral septum through a fine scalpel without any hymenal damage, then 400 ml hematoma was drained. Vaginal septum was resected completly via linear surgical stapler. Symtoms disappeared during follow up, and after two months, the dydelphic uterus clearly seen on transabdominal ultrasonography. Mullerian anomaly should be remembered in patients recently menstruating and presenting with severe dysmenorrhea.

www.esur2013.org 132 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-21 - EXTRANODAL PRIMARY DIFFUSE B-CELL LYMPHOMA WITH GYNECOLOGIC INVOLVEMENT REPORT OF TWO CASES Kılıc D. 1, Tarhan C. 1, Özen Ö. 2, Koca E. 3, Rahatlı S. 4, Ayhan A. 5 Başkent University Radiology Department Ankara-Turkey 1 Başkent University Pathology Department Ankara-Turkey 2 Başkent University Hematology Department Ankara-Turkey 3 Başkent University Medical Oncology Department Ankara-Turkey 4 Başkent University Obstetrics and Gynecology Department Ankara- Turkey 5

Objective: Extranodal lymphomas consist of 15% of all lymphomas. Most common sites of primary extranodal involvement are gastrointestinal tract, salivary glands, lungs, tyroid, orbita and skin. Genital tract involvement is extremely rare and uterine cervix is the most common site of involvement. In this report imaging findings of the diffuse B-cell lymphoma are described in two patients with gynecological involvement.

Case Presentations: A 63-year-old woman who had abdominal pain and cutaneous lesions was admitted. On abdominal CT, there was a pelvic mass which cannot be distinguished from the uterus and ovaries. On abdominal MRI, there was a solid mass originated from left ovary and also multiple solid lesions in subcutaneous tissue, right breast, bilateral adrenal glands, and retroperitoneal locations with no lymph node involvement. Pathological diagnosis was consistent with diffuse B-cell lymphoma. A 60-year-old female patient with a diagnosis of chronic hepatitis C applied with nausea and abdominal swelling. On abdominal CT study there is a large pelvic mass. Omental cake appearance and metastatic liver lesions were detected. On MRI, uterus was diffusely enlarged and showed diffuse enhancement. There were also adnexial masses. Pathologic diagnosis was diffuse B-cell lymphoma.

Conclusion: Lymphomas are mostly originated from lymph nodes but primary extranodal involvement can be seen rarely. Genital system involvement is a rare manifestation of extranodal lymphoma. Ovarian involvement has been reported only in a small number of cases and usually bilateral. Sometimes it is very difficult to distinguish ovarian lymphoma from primary ovarian carcinoma. MRI findings may be useful for differentiation.

P1-22 - MULTIDETECTOR CT FINDINGS OF RECURRENT MALIGNANT PERITONEAL MESOTHELIOMA PRESENTING INITIALLY AS A GYNECOLOGICAL TUMOR Kılıc D. 1, Tarhan C. 1, Haberal Reyhan N. 2, Altundag Ö. 3, Ayhan A. 4 Başkent University Radiology Department Ankara-Turkey 1 Başkent University Pathology Department Ankara-Turkey 2 Başkent University Medical Oncology Department Ankara-Turkey 3 Başkent University Obstetrics and Gynecology Department Ankara-Turkey 4

Aims: To describe the multidetector CT imaging findings of the recurrent disease in patients who initially presented as uterine and ovarian masses with histologically proven malignant peritoneal mesothelioma (MPM).

Methods: The follow-up multidetector CT findings of 9 women who initially had uterine and ovarian masses with histologically proven MPM were retrospectively reviewed. Most of the patients had high levels of CA- 125 initially. All CT examinations were done between 1st to 24th months after the operation. CT studies were reviewed for the presence of ascites, peritoneal involvement, mesenteric involvement, solid organ involvement and enlarged lymph nodes.

Results: Ascites and peritoneal thickening were the most common radiological findings at recurrence which were seen in 8 patients. Mesenteric implants were seen in 6 patients. In 2 patients, there were metastases in hepatic parenchyma. 2 patients had enlarged metastatic lymph nodes. 6 of the patients with second CT follow-ups had progression of findings.

Conclusion: MPM recurrences commonly present with peritoneal and mesenteric involvement. Diffuse peritoneal involvement with ascites is the most common presentation of recurrent disease similar to ovarian epithelial malignancies. Thin-slice multi-detector CT can be used as a valuable diagnostic tool to determine the recurrence and follow up of MPM.

133 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-23 - FREE-HAND ELASTOSONOGRAHY OF GYNECOLOGICAL PATHOLOGIES INITIAL RESULTS Pekindil G. 1, Soylu N. 1, Gunes Urgan S. 1 Celal Bayar University Radiology Manisa-Turkey 1

Objective:To reveal sonoelastographic findings of gynecological pathologies

Method:Totally twelve cases consisted of torsioned ovary (3), ovarian teratoma (3),tubo-ovarian absscess (2), endometrioma (2), endometrial carcinoma (1)and leiomyoma (1) were prospectively evaluated with Free- hand sonoelastography using 5-9 Mhz lineer transducer. Since the limited penetration of lineer transducer only cases within the FOV had included the study. Sonoelastography was performed by manual compression of ultrasound probe (Antares) with full bladder. The strain data were converted into color scale images (elastogram-coloured with between red-hard to purple-soft tissues) and superimposed on B-mode images. Coloured elastogram images were qualitatively evaluated by describing qualitative stifness scores ranged between 0 (no increased stifness-purple) to 4 (whole lesion had increased stifness-red).All cases confirmed with pathological examination.

Results: Endometrial carcinoma showed score 3, teratoma score 2-3, endometrioma score 1-3, tubo-ovarian absscess score 2-4, leiomyoma score 1-2. Torsioned ovary revealed score 0-1 whereas normal ovary had score 2. Additionally sonoelastography demonstrated score 3 increased stifness of adjacent tissues.

Conclusion: Although limited penetration and qualitative scores of superficial free-hand sonoelastography, it can be widely avaiable and can reveal elasticity of many gynecological pathologies. Definitive conclusions could not be made due to limited number of the cases. It can be useful to reveal peripheral increased stifness of tuboovarian absscess and to differentiate fatty tissue of teratoma from adjacent mesenteric fat. It can especially be useful to evaulate torsioned ovary by comparing normal ovary in chilhood due to superficial localization of ovaries.

P1-24 - RUPTURE DERMOID CYST WITH CHEMICAL PERITONITIS MIMICKING PERITONEAL CARCINOMATOSIS ABDOMINAL CT AND MRI FINDINGS Erbay G. 1, Karadeli E. 1, Koc Z. 1, Yalcınkaya C. 2 Baskent University Radiology Adana-Turkey 1 Baskent University Obstetrics and Gynecology Adana-Turkey 2

Objective: Mature dermoid cysts of ovarian account for % 10-25 of all ovarian masses. Dermoid cysts are often asymptomatic. The diagnosis and treatment of these lesions are usually easily made. Torsion is the most common complication, while rupture, suppuration and malignant transformation are relatively. We present radiologic findings of rupture dermoid cyst with chemical peritonitis mimicking peritoneal carcinomatosis.

Method: 54 years-old woman patient was evaluated with colonoscopy, abdominal CT and MRI ,laboratory tests for further evaluation of intraabdominal fluid.

Results: Abdominal CT showed a cystic lesion with (- 67 HU) fat attenuation that measured 9.8x5.5 cm in the right adnexial region. The second lesion containing fat-fluid levels was detected in the right iliac fossa, it was measured 6.1x3.4 cm . The dirty omentum with 3.5 cm thickness was similar to omental cake and tumour implantation. We thougt peritoneal carcinomatosis because of these findings and intraabdominal fluid. The restriction diffusion of omentum on diffusion weighted magnetic resonance images, leukocytosis , high Ca-19-9 levels were similar to peritoneal carcinomatosis findings. The suspicion defects on wall integrity of lesion on CT images and acute abdominal pain are important clues for rupture dermoid cyst. On operation, rupture dermoid cyst in the left ovary and chemical peritonitis, bowel adhesions was found. The omentectomy, total abdominal hysterectomy salpingo oophorectomy were performed.

Conclusion: Chemical peritonitis due to rupture dermoid cyst is rarely, its findings are similar to peritoneal carcinomatosis.

www.esur2013.org 134 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P1-25 - MRI IN THE DIAGNOSIS OF MAYER-ROKITANSKY-KUSTER-HAUSER SYNDROME Kara T. 1, Acu B. 1, Beyhan M. 2, Gökçe E. 2 Eskişehir Osmangazi University Medical Faculty Department of Radiology Eskişehir-Turkey 1 Gaziosmanpaşa University Medical Faculty Department of Radiology Tokat-Turkey 2

Purpose : The aim of this study was to establish the role of magnetic resonance imaging (MRI) in patients with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS).

Materials and Methods: Sixteen female MRKHS patients (mean age, 19.4 years; range, 11–39 years) were studied using MRI. Two experienced radiologists evaluated all the images in consensus to assess the presence or absence of the ovaries, uterus, and vagina. Additional urogenital or vertebral pathologies were also noted.

Results : Of the 16 patients, complete aplasia of uterus was seen in five patients (31.3%). Uterine hypoplasia or remnant uterus was detected in 11 patients (68.8%). Ovaries were clearly seen in 10 patients (62.5%), and in two of the 10 patients, no descent of ovaries was detected. In five patients, ovaries could not be detected on MRI. In one patient, agenesis of right ovary was seen, and the left ovary was in normal shape. Of the 16 cases, 11 (68.8%) had no other extragenital abnormalities. Additional abnormalities were detected in six patients (37.5%). Two of the six had renal agenesis, and one patient had horseshoe kidney; renal ectopy was detected in two patients, and one patient had urachal remnant. Vertebral abnormalities were detected in two patients; one had L5 posterior fusion defect, bilateral hemisacralization, and rotoscoliosis, and the other had coccygeal vertebral fusion.

Conclusion : MRI is a useful and noninvasive imaging method in the diagnosis and evaluation of patients with MRKHS.

135 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 2 - Oncologic Imaging of the Urogenital System

P2-01 - PENILE MASS QUANTITATIVE SHEAR WAVE ELASTOGRAPHY CORRELATED WITH MAGNETIC RESONANCE IMAGING Kilic F. 1, Ustabasioglu F. 1, Korkmazer B. 1, Samanci C. 1, Mihmanli İ. 1, Kantarci F. 1 Istanbul University Cerrahpasa Medical faculty Radiology Istanbul-Turkey 1

Objective: The purpose of this study was to present quantitative shear wave elastography (SWE) and magnetic resonance imaging (MRI) findings in two cases of penile mass.

Method : Case 1: A 31-year-old man presented with penile curvature and pain during erection. The patient was referred to our clinic for Doppler ultrasound examination with suspicion of Peyronie’s disease. In gray- scale imaging an expansile mass was noticed in the left corpus cavernosum. Detailed history revealed a recent vigorous sexual intercourse. Upon this we performed SWE and MRI. Case 2: A 71–year-old man, with bladder cancer, was admitted to our clinic with palpable penile masses. Multiple cavernosal lesions were revealed on ultrasonography. Then we performed SWE and MRI.

Results :In the first case the mean elasticity value of cavernosal mass and contralateral normal corpus cavernosum had an elasticity value of 86 and 21 kPa; respectively. Since both T1-weighted and T2-weighted images on MRI were hypointense fibrosis was presumed. The mean elasticity value of penile metastatic mass was 299 kPa, whereas it was measured 37 kPa in normal corpus cavernosum for the second case. In penile MRI there were multiple T1 hypointense and T2 hyperintense lesions involving cavernosal bodies.

Conclusion:SWE provides additional quantitative data in the differentiation of benign and malignant masses when compared with gray-scale ultrasonographic imaging.

P2-02 - INTRADIVERTICULAR TRANSITIONAL CELL CARCINOMA OF THE BLADDER Hadjidekov G. 1, Tzvetankov K. 1, Plachkov I. 1 University Hospital Lozenets Radiology Sofia-Bulgaria 1

Introduction: We present a case of a 63 year old man misdiagnosed via cystoscopy by a bladder tumor and further evaluated with ultrasound and MRI to diagnose intradiverticular bladder carcinoma. Carcinomas arising within urinary bladder diverticula have a poorer prognosis than do neoplasms originating within the main bladder lumen because the thinner diverticular wall allows earlier spread.

Materials and methods: Due to the inconclusive cystoscopic findings in this patient with asymptomatic hematuria ultrasound was performed followed by magnetic resonance imaging. On histopathology the diagnosis of intradiverticular transitional cell carcinoma of the bladder has been confirmed.

Results: The cystoscopic evaluation reveals a papillary tumor formation of the bladder wall. US demontrastrated hypoechoic, intracavitary, well vascularised mass with extralumenal propagation. MRI confirmed the presence of huge bladder diverticula, extending from the posterior lateral wall in the basis of the bladder. The diverticula is almost entirely occupied by the tumor, obturate the ostium and spreads into the bladder cavity. A thin layer of urine bathes the tumor mass leaving the posterior and the medial wall of the diverticula intact.

Conclusions: Diverticular bladder tumors are a rare condition manifested mainly with painless microscopic or macroscopic heamaturia. MR is the method of choice after cystoscopy for staging infiltration of the bladder wall, local spread and invasion. MRI is particularly beneficial in cases of cystoscopically missed intradiverticular tumor, misinterpreted as a solid mass. Intradiverticular carcinomas results of earlier spread and is considered as a major prognostic factor.

www.esur2013.org 136 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-03 - STRAIN ELASTOGRAPHY IN THE CHARACTERIZATION OF RENAL MASSES PRELIMINARY RESULTS Keskin S. 1, Güven S. 2, Keskin Z. 3, Özbiner H. 1, Kerimoğlu Ü. 1, Yeşildağ A. 1 Necmettin Erbakan University, Meram School of Medicine Radiology Konya-Turkey 1 Necmettin Erbakan University, Meram School of Medicine Urology Konya-Turkey 2 Konya Training and Research Hospital Radiology Konya-Turkey 3

Objective: To evaluate the diagnostic performance of strain elastography to differentiate benign from malignant renal lesions.

Method: Strain elastography was performed in 69 patients (mean age 56.1 years; range 32–81 years) who had renal lesions (26 benign and 43 malignant) prospectively. Lesions were classified according to lesion size and histological subtypes. The strain ratios of the benign and malignant lesions were evaluated by a radiologist. The area under the curve and cut-off point was used to assess diagnostic performance. Sensitivity, specificity, and positive and negative predictive values were obtained.

Results: The mean strain ratio for <20 mm lesions was 1.5 ± 0.5 (range 0.06–5.92), for 20–40 mm lesions was 2.7 ± 0.4 (range 0.17–9.92), and for >40 mm lesions was 2.7 ± 0.3 (range 0.08–6.15). When benign and malignant lesions were compared, there was a statistically significant difference in the strain ratio among the three groups (P = 0.04). For the strain ratio, the mean ± standard deviation was 1.2 ± 0.2 for benign lesions and 3.4 ± 0.3 for malignant lesions (P < 0.01). When lesion subtypes were compared, there was a statistically significant difference in the strain ratio between the angiomyolipoma and the clear cell renal cell carcinoma (P < 0.01).

Conclusion: For assessing renal lesions, strain elastography and strain ratio values may be useful in differentiating benign from malignant renal lesions.

P2-04 - SEMINOMA IN INTRAABDOMINAL UNDESCENDED TESTIS US FINDINGS Celikkanat S. 1, Inan K. 1, Deveci M. 2, Saglam M. 1 Gulhane MMA Radiology Ankara-Turkey 1 Gulhane MMA Pathology Ankara-Turkey 2

Objective: Cryptorchidism is a rare congenital anomaly associated with infertility. Germ cell tumors especially seminomas occur 3-5 times more frequent in the abdominally located testis than the scrotal ones. In this poster we aimed to discuss US findings of this entity with a standard ultrasonography device.

Method: A 27-year-old adult with right lower quadrant pain and absence of one testis in scrotum was referred to our department of radiology for the suspicion of undescended testis. We performed standard gray scale and color duplex mode US.

Results: Vital right testis was visualized in the original location in scrotum without any solid or cystic mass in parenchyma. Left testis wasn’t visualized in scrotum. We performed gray scale US both lower quadrants and visualized left testis abdominally located in the right lower quadrant. We depicted two solid lesions that have blood supply in the inferior pole of the undescended intraabdominal testis. In addition to that we visualized omentum surrounding spermatic cord and leading to scrotum.

Conclusion: Undescended testes are infrequent congenital condition in men and can be associated with tumors like seminomas. Malignant intraabdominal testes can range from an asymptomatic masses to mimicking acute abdominal pain like appendicitis, retroperitoneal mass, incarcerated hernia and torsion. Standard gray scale and color duplex mode US should be considered as a noninvasive diagnostic procedure to be showing the several other lesions and a good delineation of anatomical structures of pelvic region.

137 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-05 - TEN TIPS (A TO I’S) FOR CHARACTERIZATION AND DIFFERENTIAL DIAGNOSIS OF RENAL MASS ON CT MRI Gokan T. 1, Sasamori H. 1, Ohgiya Y. 1, Ogawa Y. 2, Takimoto M. 3 Showa University Hospital Radiology Shinagawa-ku-Japan 1 Showa University Hospital Urology Tokyo-Japan 2 Showa University Hospital Pathology Tokyo-Japan 3

Objective: To show ten tips of CT/MR findings and techniques which radiologist need to know for characterization and differential diagnosis of renal mass.

Method : Ten tips (A to I’s) of CT/MR findings and techniques which are useful to characterize and differentiate renal mass are shown with discussion and appropriate clinical cases are presented with potential pitfalls. Results: Presented ten tips (A to I’s) are as follows.

A: Attenuation on unenhanced CT B: Bosniak Classification. C: Capsule (Pseudocapsule) D: Diffusion-weighted images E: Enhancement pattern F: Fat (macroscopic fat) H: Homogeneity I: Intracellular lipid (microscopic fat) S: Signal intensity on MRI

Conclusion:In most cases, characterization and differential diagnosis of renal mass will be possible with CT/MRI using ten tips as shown in this presentation. However, there are some cases in which the correct diagnosis is still difficult and percutaneous needle biopsy may be necessary for final diagnosis.

P2-06 - CONCURRENT RENAL CELL CARCINOMA AND RENAL ANGIOMYOLIPOMA IN THE IPSILATERAL KIDNEY Sung D. 1, Kang K. 1, Han N. 1, Park B. 1, Kim M. 1, Cho S. 1 Anam Hospital, Korea University Radiology Seoul -Korea, South 1

Objective: To report a case of renal cell carcinoma (RCC) and renal angiomyolipoma (AML) concurrently involving the ipsilateral kidney with CT and MRI findings.

Background: Concurrent RCC and AML is a very rare condition, and it is hard to differentiate RCC from non-fatty portion of AML. But, some radiologic findings may raise a suspicion of coexistence of RCC and renal AML.

Content: We present our experience with a large ruptured AML and a growing RCC in a 65‐year‐old woman. Initial CT revealed a well-enhancing soft-tissue lesion adjacent to a fatty component of AML in the ipsilateral kidney. On serial follow-up CT, the strongly enhancing lesion enlarged relatively rapidly to the vascular and muscular components of AML. The growing lesion, which presented as a well-defined mass with T2 high signal intensity on MRI, showed delayed washout on contrast-enhanced T1-weighted image and marked diffusion restriction on diffusion-weighted image. Histopathological examination of the well-enhancing mass confirmed the diagnosis of RCC.

Conclusion: A rapidly growing component in AML with T2 high signal intensity, strong arterial enhancement and delayed washout, and marked diffusion restriction should be biopsied and characterized histopathologically.

www.esur2013.org 138 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-07 - PERIRENAL FAT INVASION ON RCC EVALUATED BY MULTIDETECTOR CT RADIOLOGIC- PATHOLOGIC CORRELATION Tsili A. 1, Goussia A. 2, Ntorkou A. 1, Baltogiannis D. 3, Sofikitis N. 3, Malamou-Mitsi V. 2, Argyropoulou M. 1 Medical School-University of Ioannina Clinical Radiology Ioannina-Greece 1 Medical School-University of Ioannina Pathology Ioannina-Greece 2 Medical School-University of Ioannina Urology Ioannina-Greece 3

Objective: To assess the accuracy of multidetector CT in diagnosing perinephric (PN) and/or renal sinus (RS) fat invasion in patients with RCC, in correlation with histopathologic findings.

Method: This was a retrospective study of 48 histologically proven RCCs. Examinations were performed on a 16-row CT scanner, including unenhanced and three-phase (arterial, portal and nephrographic-excretory phase) contrast-enhanced CT scanning. Unenhanced transverse images and multiplanar reformations in the transverse, coronal and sagittal planes of each contrast-enhanced CT phase were evaluated. The Chi- square 2 way test was used to assess the significance of association between CT findings in the diagnosis of PN and/or RS fat invasion. The predictive value of CT findings in diagnosing PN and/or RS fat invasion was determined using multivariate logistic regression analysis. Pathologic diagnosis was used as the standard of reference.

Results: There were 12 RCCs with PN fat invasion and 11 with RS fat invasion, proved pathologically. The CT findings that were most predictive for the diagnosis of PN fat invasion were the presence of contrast- enhancing nodules in the perinephric fat and tumoral margins, with an accuracy of 85.4% and 85.4%, respectively. Invasion of the pelvicaliceal system was the most significant predictor in the diagnosis of RS fat invasion, with an accuracy of 93.7%.

Conclusion: Multidetector CT provides satisfactory results in detecting perinephric and/or renal sinus fat invasion on RCC.

P2-08 - VALUE OF FAT-SUPPRESSED T2-WEIGHTED MR IMAGING AS A VIRTUAL BIOPSY TOOL IN THE INDETERMINATE RENAL MASSES IN CT Choi H. 1, Cho K. 1 Asan Medical Center Radiology Seoul-Korea, South 1

Purpose: To assess the usefulness of fat-suppressed T2 (FST2) MR imaging for indeterminate renal masses in CT as a substitute for biopsy.

Materials and methods: We retrospectively evaluated 168 patients with pathologically and clinically diagnosed renal masses, all of which were indeterminate in diagnosis in CT images. Signal intensity ratio (SIR) in FST2 images and visual comparison of tumor signal to adjacent renal parenchyma were done for each tumor by two readers. Diagnostic accuracies for SIR and visual comparison were acquired.

Results: The sensitivity, specificity, positive predictive value, and negative predictive values in SIR measurement were 71%, 85%, 97%, 28% for reader 1 and 69%, 75%, 95%, 25% for reader 2, respectively (correlation coefficient = 0.94). The correlation coefficient for The sensitivity, specificity, positive predictive value, and negative predictive values in visual comparison were 70%, 85%, 97%, 27% for reader 1 and 71%, 80%, 96%, 27% for reader 2, respectively (kappa = 0.90).

Conclusion: With use of FST2 MR imaging, renal cell carcinoma can be diagnosed with high predictive value. Considering the low diagnostic rate of small renal mass this FST2 MR imaging can be a useful virtual biopsy tool for indeterminate renal masses.

139 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-09 - RADIOLOGIC FEATURES OF RENAL EPITHELIOID ANGIOMYOLIPOMA A RARE MESENCHYMAL TUMOR MIMICKING MALIGNANT RENAL MASS ON CROSS-SECTIONAL IMAGING Harman M. 1, Acar T. 2, Elmas N. 1, Sever A. 1, Sen S. 3 Ege University School of Medicine Radiology Izmir-Turkey 1 Bayindir State Hospital Radiology Izmir-Turkey 2 Ege University School of Medicine Pathology Izmir-Turkey 3

Objective: To report MRI and CT features of two cases pathologically confirmed with epithelioid angiomyolipoma(EA), a rare mesenchymal tumor of kidney.

Method: Fifty-three years old woman with left flank pain underwent MRI and 30 years old woman with right flank pain underwent CT work-up. Both of them had no history of tuberous sclerosis(TS). After demostrating kidney masses with imaging on the symptomatic kidneys, radical nephrectomy performed and kidney specimens were evaluated pathologically.

Results: On MRI examination; a 6 cm kidney mass with infiltrative characteristics, orginating from central part of the left kidney than reaches to pelvicaliceal system, on CT evaluation; an infiltrating 7x6 cm right kidney mass, orginating from right upper pole of kidney than reaches to renal sinus, were detected. CT examination demostrated tumor thrombus in both renal vein and inferior vena cava. Both tumors lacks of fat in imaging. Radical nephrectomy performed for each patients and specimens were proved to be epithelioid angiomyolipoma with immunohistochemical stains HMB-45 Melan-A

Conclusion: EA account for 8% of renal angiomyolipomas, show a high degree of association with tuberous sclerosis(TS), and demostrate aggresive behaviour . At gross examination, EA is a large infitrative necrotic tumor with occasional extension into renal vein or inferior vena cava. However without history of TS and low fat values on imaging, EA(s) would be a changing diagnosis for radiologists which may lead malignant mass over-diagnose.

P2-10 - MAGNETIC RESONANCE IMAGING FINDINGS OF TESTICULAR ADRENAL REST TUMORS IN CONGENITAL ADRENAL HYPERPLASIA Koç U. 1, Aygün M. 2, Mutlu Aygün F. 3 Suleyman Demirel University Department of Radiology ISPARTA-Turkey 1 Konya Education and Research Hospital Department of Radiology KONYA-Turkey 2 Konya State Hospital Department of Radiology KONYA- Turkey 3

Introduction:Congenital adrenal hyperplasia(CAH) is an inherited disorder affecting the steroid synthesis of the adrenal gland. One of the most important and frequently detected complications in male CAH patients is the development of testicular tumors. Since then testicular tumors have been described in several papers, mainly case reports. Because of the morphological and functional resemblance with adrenal tissue they are called testicular adrenal rest tumors (TART). Herein we report magnetic resonance imaging(MRI) findings of testicular adrenal rest tumors of two adult patients with congenital adrenal hyperplasia.

Case report:Two adult men consulted to our clinic with scrotal swelling. All patients underwent scrotal ultrasound which showed bilateral solid hypo echoic mass with focal calcification focuses. T2 weighted MR images showed hypointense lobulated mass testicular lesions in the testicular hilus.

Discussion:TART is the most important cause of infertility in adult male CAH patients. They are not malignant but longstanding TART can result in irreversible damage of testicular tissue and subsequently infertility. The presence of TART in children is described mostly in case reports and only a limited number of studies describe its prevalence in larger populations of children and adults. Vanzulli et al. described a prevalence of 27% of TART in a group of 30 CAH patients between 9 and 32 years old. MRI findings of TART is discussed on the basis of recent literatures.

Key Words:Testicular Adrenal Rest Tumors, Infertility, MRI , Congenital Adrenal Hyperplasia

www.esur2013.org 140 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-11 - PELVIC MRI IN UROGENITAL ONCOLOGY LOOKING BEYOND THE ORGAN OF INTEREST George C. 1, James A. 1, Clark A. 1, Jacob A. 1 University Hospital of North Staffordshire Imaging Stoke-on-Trent-United Kingdom 1

Magnetic Resonance Imaging (MRI) is extensively used in the diagnostic work-up of uro-genital oncology patients. MRI serves as the imaging modality of choice in the local staging of a number of gynaecological and urological malignancies within the pelvis. Incidental findings outside the organ of interest may represent benign or malignant conditions. Recognition of these incidental findings is essential in providing the appropriate treatment or management for these patients. This pictorial review demonstrates various incidental MRI findings encountered in patients scanned for pelvic uro-genital malignancy, with a brief mention of their clinical significance and management.

P2-12 - PRELIMINARY RESULTS OF EARLY ASSESSMENT OF RESPONSE WITH PERFUSION-CT IN PATIENTS WITH METASTATIC RENAL CELL CARCINOMA (MRCC) TREATED WITH SUNITINIB Sebastia C. 1, Reig O. 2, Paño B. 1, Mellado B. 2, Salvador R. 1, Nicolau C. 1 Hospital Clinic Radiology Barcelona-Spain 1 Hospital Clinic Oncology Barcelona-Spain 2

Purpose: To evaluate the patterns of response with perfusion-CT, one month after the beginning of the antiangiogenic treatment in mRCC and correlation with radiologic evolution (RECIST)

Materials and methods: Patients with metastatic renal cell carcinoma and candidates for sunitinib treatment were selected. A volumetric study (21 cm) with perfusion-CT (Flash Definition, Siemens, Erlangen, Germany) was done before starting the treatment, 1 and 4 months after the antiangiogenic initiation. We defined types of response patterns based on changes in density (D), perfusion (P) and size (S) of the metastases.

Results: From March 2011 to May 2012, 16 patients were included. The median age was 62 years, the majority of patients had clear cell RCC (n=13, 81.25%) and good prognosis (n=14, 87.5%), based on Motzer and Heng criteria. In 12 patients a decrease of D and P was observed despite the size. This pattern was correlated with a partial response in 8 patients and stable disease in other two patients. Two patients were lost in the follow-up. The increase of S, associated with a decrease of P and D was found in two patiens with partial reponse. Stability of D, P and S was found in one patient with stable disease. An increase of D and P despite of size was related with progressive disease in one patient and with stability in another case.

Conclusion: Only the patients who presented increase in D and P present progressive disease in later follow-up by RECIST.

P2-13 - UPPER URINARY TRACT UROTHELIAL CELL CARCINOMA STAGING IN MULTI-DETECTOR CT UROGRAPHY ERA A COMPREHENSIVE REVIEW Yoon S. 1, Kim D. 1, Cho J. 1, Oh J. 1, Nam K. 1 Dong-A University Medical Center Radiology BUSAN-Korea, South 1

Urothelial cell carcinoma (UCC) is uncommon and accounts for up to 10% of neoplasms of the upper urinary tract. It is commonly multifocal with a high incidence of recurrence requiring rigorous urothelial surveillance. The multicentricity of UCC makes assessment of the entire urothelium essential before treatment. Imaging plays an important role in assessment of upper urinary tract urothelial cell carcinoma (UUT-UCC), unlike in bladder UCC, diagnosis of which is usually made at cystoscopy. Among the imaging modalities, multi- detector CT urography (MDCTU) becomes more prevalent and it is likely to become the investigation of choice, as the urothelium, renal parenchyma, and perirenal tissues can be assessed at a single examination. The TNM system is most frequently used for staging UUT-UCC. The tumor stage at diagnosis influences the development of local recurrence and metastases and hence overall survival. MDCTU is being advocated as a one-stop diagnostic and staging assessment of suspected urothelial malignancy. Accurate radiologic detection and staging of UUT-UCC is essential to determine appropriate surgical therapy, chemotherapy, or radiation therapy.

141 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-14 - MULTILOCULAR CYSTIC RENAL CELL CARCINOMA IMAGING FINDINGS IN A SERIES OF 7 PATIENTS Altay C. 1, Secil M. 1, Aslan G. 2, Demir O. 2, Tuna B. 3, Yorukoglu K. 3 Dokuz Eylul University Faculty of Medicine Department of Radiology Izmir-Turkey 1 Dokuz Eylul University Faculty of Medicine Department of Urology Izmir-Turkey 2 Dokuz Eylul University Faculty of Medicine Department of Pathology Izmir-Turkey 3

Objective: Multilocular cystic renal cell carcinoma (RCC) is a rare form of the renal carcinomas characterized histologically by cystic masses with or without solid areas. The purpose of this study was to describe the imaging findings of this pathology in a series of patients.

Method: We retrospectively reviewed the sonography, CT and/or MR imaging studies of 7 patients who were operated and received the diagnosis of multilocular cystic RCC between January 2005 and May 2013.

Results: The patients comprised of 4 men and 3 women with a mean age of 53.2 years (range 37-61 years). The mean tumor size was 6.25 cm (range 3 to 10) for multilocular cystic RCC. The MRI characteristics of the masses were generally hypointense on T1, hyperintense on T2, enhancing with gadolinium chelate contrast agents at the septa, cyst wall and/or the solid portion of the mass. CT images generally showed the lesions as semisolid masses with large cystic components. In all radiologic examinations, the margins of renal masses were well defined, and no sign of infiltration of the adjacent tissue.

Conclusion: Multilocular cystic RCCs present with a complex cystic mass. Enhancing septa or wall and presence of solid component may be used to differentiate them from other cystic lesions that do not necessitate surgery.

P2-15 - UNCLASSIFIED RENAL CELL CARCINOMA RADIOLOGICAL-PATHOLOGICAL CORRELATION OF AN UNCOMMON SUBTYPE Secil M. 1, Altay C. 1, Aslan G. 2, Demir O. 2, Tuna B. 3, Yorukoglu K. 3 Dokuz Eylul University Faculty of Medicine Department of Radiology Izmir-Turkey 1 Dokuz Eylul University Faculty of Medicine Department of Urology Izmir-Turkey 2 Dokuz Eylul University Faculty of Medicine Department of Pathology Izmir-Turkey 3

Objective: Unclassified renal cell carcinoma (RCC), is a relatively rare subtype of renal cancer which was described in 1997. The purpose of this study was to describe the imaging findings of unclassified (RCC).

Method: A total of 18 patients histopathologically diagnosed as unclassified RCC at our institution during the period of last 8 years were retrospectively evaluated. The radiological and pathological features of unclassified RCCs were investigated and demonstrative images were presented.

Results: The patients comprised of 14 men and 4 women with a mean age of 61.7 years (range: 50-75 years). Mean lesion size at the diagnosis was 6.7 cm (range 3.1 to 15.8). TNM stages of tumors were T1 in 1, T2 in 3, T3 in 13, T4 in 1 of patients. All patients with unclassified RCC, 78% had Fuhrman grades III or IV. The detected tumors were found to be heterogeneous (92%) and hypervascular (63%), infiltratively growing (66%) in nature on imaging.

Conclusion: Radiologic examinations are important in the diagnosis, management and surveillance of patients with RCC. The imaging findings of unclassified RCC overlap with those of other renal tumors, although the unclassified RCC commonly presents with significantly larger and more aggressive tumors.

www.esur2013.org 142 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-16 - COMPLICATIONS OF PARTIAL AND TOTAL NEPHRECTOMIES A PICTORIAL REVIEW OF IMAGING FINDINGS George C. 1, James A. 1, Thomas B. 1, Luscombe C. 2, Golash A. 2 University Hospital of North Staffordshire Imaging Stoke on Trent-United Kingdom 1 University Hospital of North Staffordshire Urology Stoke-on-Trent-United Kingdom 2

Treatment of renal cell carcinomas have evolved over the years from what was once the standard radical nephrectomy to the recent advances of management by laparoscopic partial or nephron-sparing nephrectomies. The possible complications of nephrectomies include vascular, collecting system, and technical complications,and infection. Radiologists should be familiar with the spectrum of possible imaging findings following such complex procedures so that a prompt diagnosis leading to appropriate management is made. This pictorial review demonstrates the imaging findings of partial and total nephrectomies encountered in clinical practice.

P2-17 - STAGING OF RENAL CELL CARCINOMA SPECTRUM OF IMAGING FINDING ON MDCT Moon S. 1, Lim J. 1 Kyung Hee University Hospital Radiology Seoul-Korea, South 1

Objective: To illustrate CT staging of renal cell carcinoma (RCC) and to discuss adequate preoperative radiologic assessment to determine treatment

Method: We retrospectively reviewed the imaging features of pathologically-confirmed RCC. For staging of RCC, following imaging features were assessed; tumor size, tumor interface with renal parenchyma; perinephric tumor extension; the presence and extent of venous invasion; spread into contiguous organs; adrenal gland involvement; local or distant metastasis.

Results : T1 and T2 tumors usually have discrete tumor margin, and are limited to the kidney. T1 tumors (<7cm) could be treated with partial nephrectomy. Partial nephrectomy for T2 (>7cm) also appears to be effective especially for a highly selective group of patients (those with a solitary kidney, preexisting renal insufficiency, and an appropriate tumor location). Renal sinus fat invasion and perinephric fat invasion are grouped together as category T3a. Renal vein invasion thrombosis is reassigned to T3a. T3b and T3c tumors are considered IVC involvement with tumor thrombus. T4 tumors with Gerota’s fascia invasion shows direct tumor invasion with loss of fat planes between the tumor and adjacent structures, and density change of adjacent structures.

Conclusison: Adequate preoperative CT staging of RCC provides the physician with information critical in determining the sequence of treatments; surgical approach, and timing of systemic therapy for metastatic disease.

P2-18 - A CASE OF LEIOMYOSARCOMA OF URINARY BLADDER WHICH MIMICKS HEMANGIOMA Kim M. 1, Kim Y. 1 Hanynag University Guri Hospital Radiology Guri-Republic of Korea 1

A 17-year old man was admitted to our urology department for evaluation of gross hematuria with terminal dysuria. He had no other clinical or laboratory abnormalities. CT of the urinary bladder revealed a 4cm-sized lobulating polypoid mass at dome area without perivesical infiltration. The mass showed heterogeneous enhancement with central nonenhancing portion. On sequential MRI of pelvis, the mass was located in subepithelial layer and showed heterogeneously high signal intensity on T2 weighted images and low signal intensity with some hyperintense spots on T1 weighted images suggesting hemorrhage. Dynamic enhancement MRI of the mass demonstrated centripetal enhancement and the degree of enhancement was similar to adjacent external iliac vessels. The patient underwent partial cystectomy and the mass was confirmed to low grade leiomyosarcoma.

143 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-19 - TESTICULAR LEIOMYOMA A RARE CASE OF INTRATESTICULAR MASS Tepe M. 1, Kara T. 1, Açıkalın M. 2, Kebapçı M. 1, Acu B. 1 Eskişehir Osmangazi University Hospital Radiology Eskişehir-Turkey 1 Eskişehir Osmangazi University Hospital Pathology Eskisehır-Turkey 2

Objective: Intratesticular masses are usually considered to be malignant. Leiomyoma is an extremely rare, benign etiology of a intratesticular mass. We found only 8 cases of intratesticular leiomyoma, those have been reported in the English language literature to date. We present sonographic and histopathologic features of a case of palpable testicular mass which was proved to be a intratesticular leiomyoma on pathologic examination.

Method: Thirty three year old male presented with complaints of a palpable right testicular mass that he had noticed at 2 months ago. On physical examination, a firm and non-tender mass was palpated on right testicle. Scrotal ultrasound was performed.

Results: Scrotal ultrasound showed a hypoechoic, homogeneous, well-circumcised solid mass 7x6x9 mm in size, located at mid-anteroportion of right testis. Preoperative diagnosis was a tumor of testicular origin which could be probably malignant. Intraoperative frozen result showed no malign findings on the specimens so surgery was completed with partial orchiectomy. Permenant pathologic examination revealed as a pure leiomyoma arising from the testicular paranchyma.

Conclusion: Sonographic reports have described intratesticular leiomyomas as solid,well-defined, hypoechoic or heterogeneous masses that may contain calcification. On histopathologic examination , the tumour is composed of whorling bundles of smooth muscle cells. In immunohistochemical staining, the tumor cells are positive for vimentin, desmin, actin. All intratesticular tumors are assumed to be malignant until proven otherwise. Testis sparing surgery is possible as long as frozen specimen confirms the benign diagnosis. When encountering a solid intratesticular mass, leiomyoma should be kept in mind as differantial diagnosis.

P2-20 - PRIMARY RENAL SYNOVIAL SARCOMA Balyemez F. 1, Acar M. 1, İnan İ. 1, Ayaz E. 1 Medeniyet University Goztepe Research and Training Hospital Radiology İstanbul-Turkey 1

Objective: Primary renal synovial sarcoma(SS) is a rare tumor first described by Argani in 2000 . Its presentation is similar to that of other renal tumors. Th e diagnosis is confirmed by immunohistochemical stain or cytogenetic study. MRI findings can be helpful for estimating the diagnosis and prognosis.

Method:Here, we present a case of a 45-year-old male, presenting with abdominal distention, left flank pain and hematuria for two months. MRI was performed. The patient underwent left radical nephrectomy.

Results:MRI revealed a large heterogeneous well defined mass lesion on the middle zone of the left kidney, extending into the renal pelvis and the perinephric region. On T1 weighted imaging, the mass was heterogeneous, with the anterior region having similar intensity to skeletal muscle and the posterior region with higher signal intensity. T2 weighted images revealed marked heterogeneity with areas of high, intermediate, and low signal, known as the ‘triple sign. Our prospective diagnosis was renal cell carcinoma.

Conclusion: Primary SS of the kidney is a rare tumor. The presentation of SS of the kidney is non-specific, and resembles that of other primary tumors of the kidney. Patients may complain of localized flank pain, hematuria, or a palpable abdominal mass. MRI or CT findings are usually non-specific for SS. Local recurrence and metastatic disease are common. Prognosis is extremely poor. High grade SS is favored in tumors that exhibit cystic components, hemorrhage, and fluid levels, as well as the triple sign. Absence of calcification was also weakly associated with

www.esur2013.org 144 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-21 - MRI IMAGING OF PELVIC GIST Demir P. 1, Turgut A. 1, Koşar P. 1, Ergün E. 1, Çosar M. 1, Yiğit H. 1, Öztekin P. 1 Ankara Hastanesi Radiology Ankara-Turkey 1

Objective: To report the clinical presentation and radiologic outcomes of three patients who presented with an pelvic mass and were diagnosed with a gastrointestinal stromal tumor (GIST).

Methods: Datas were obtained on three patients who presented with an pelvic mass and were ultimately diagnosed with a GIST. On imaging studies, three patients had MRI.

Results: One patient had a tumor arising from the prostate and he had liposarcoma at the time, one from vagina, one from omenthum . The mean tumor size was 14 cm (range, 7 to 17 cm). The mean age was 42 years (range, 31 to 65 years). At MRI imaging, tumors appear as large, hypervascular enhancing masses that frequently harbor areas of necrosis, hemorrhage, or cystic degeneration. Areas of low signal intensity representing fibrosis may be seen on T2-weighted MR images. All patients underwent operation and had a pathological diagnosis.

Conclusion: GISTs are uncommon; however, they should be considered in the differential diagnosis of patients presenting with pelvic mass.

P2-22 - GIANT PELVIC SCHWANNOMA A CASE REPORT Koşar P. 1, Demir P. 1, Öztekin P. 1, Ergün E. 1, Turgut A. 1, Kaçar M. 1 Ankara Hospital Radiology Ankara-Turkey 1

Abstract: Schwannomas occurring in the pelvis are rare and account for only 1% of cases. We will report giant pelvic schwannoma in our case.

Case report:A case is reported of a 43 -year-old woman with complaints of general malaise and bilatheral lumbar pain. Bilateral hydronephrosis and a giant pelvic tumor were found by ultrasonography. İn magnetic resonance imaging showed the heterogenous tumor in the pelvis with cystic components. The tumor was 10.8 11.1 13 cm in diameter. The pelvic cavity was occupied by the tumor rigidly adhered to the sacrum and cause anterior displacement of the rectum. The tumor was extirpated following diagnosis as a benign neurogenic tumor by needle biopsy. The histopathological diagnosis of the specimen was benign schwannoma, type Antoni A.

Results: Although schwannomas commonly occur in the extremities, more rare sites of occurrence such as presacral locations in pelvic should always be considered in the differential diagnosis of a pelvic mass.

P2-23 - ROLE OF T2WI IN DETECTION OF CONNECTIVE TISSUE STALK IN TRANSITIONAL CELL CARCINOMA OF THE URINARY BLADDER Abou-Bieh E. 1, Abou-ElKher R. 1, El-Diasty T. 1, Barentsz J. 2 Urology & Nephrology Center Radiology Mansoura-Egypt 1 University Medical Center Radiology Nijmegen- Netherlands Antilles 2

Purpose: To detect the accuracy of high-resolution T2w-imaging (HR-T2WI) in detection of connective tissue stalk in transitional cell carcinoma of the urinary bladder.

Patients & Methods:Retrospective study including 867 patients cystoscopic proven to have urinary bladder mass and examined radiologically by axial HR-T2wi of MR imaging at 1.5T machine at a period of 17 months. These results were compared with post-operative histopathology to detect presence of the central connective tissue stalk.The accuracy of the MRI technique was calculated.

Results: 48/867 (5.5%) cases were radiologically diagnosed as connective tissue stalk of transitional cell carcinoma. 3/48 (6.25%) cases were inoperable so, they out of study. Compared to post-operative histopathological examination 2/45 cases (4.4%) were cystitis, 1/45 cases (2.2%) was adenocarcinoma and 2/45 (4.4%) cases were squamous cell carcinoma. So, 40/45 cases (88.9%) were correctly diagnosed by MRI study.

Conclusion: HR-T2wi of MR imaging is a highly accurate MRI sequence in detection of connective tissue stalk in transitional cell carcinoma of the urinary bladder.

145 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-24 - PICTORIAL REVIEW OF DISCREPANCIES IN ONCOLOGIC IMAGING OF UPPER GENITOURINARY TRACT - REFLECTIONS AND LESSIONS LEARNT Lay J. 1, Yeung G. 1 Royal Bolton Hospital Radiology Bolton-United Kingdom 1

Objective : We present our collection of cases where there is significant clinico-radiological discrepancy over a 4 year period

Method : Approximately 60 renal and ureteric carcinomas are diagnosed in our institution each year. From the hospital cancer database we have identified all cases where there have been important diagnostic errors in the investigation pathway. False negatives, false positives and staging discrepancies are included. We review all relevant images, reflect on the nature of the discrepancies and report on the points learnt and action taken.

Results : Common causes of errors include: 1. inadequate distention or opacification of the collecting system on CT urogram 2. difficulty differentiating benign from malignant ureteric strictures 3. characterization of renal pseudotumours 4. rare renal carcinomas with unusual clinical presentation 5. interpretation of negative histology result, especially for calyceal lesions 6. presence of co-existing abnormality causing difficulty in image interpretation 7. failure of recognition of diffuse skeletal and hypervascular liver metastases 8. sub-optimal MR sequences 9. missed extra-renal lesions

Conclusion : ‘Error’ is but a measure of variance from the perfect result, but observer errors can be reduced by meticulous imaging technique, knowledge of normal variants and benign changes, careful systemic inspection of all anatomic compartments, better decision making based on knowlege of clinical history and relevant pathology and careful review of previous imaging findings. All cases should be discussed in a multi- disciplinary team setting so that the risks and benefits of biopsy or follow up imaging can be considered on an individual basis.

P2-25 - BLADDER CARCINOSARCOMA ACCOMPANIED WITH BLADDER STONE Inan I. 1, Acar M. 1, Senturk S. 1, Balyemez F. 1, Ayaz E. 1 Medeniyet University Goztepe Research and Training Hospital Radiology İstanbul-Turkey 1

Objective: Bladder carcinsarcomas are very rare and aggressive tumors with poor prognosis. To our knowledge, approximately 95 cases have been reported up to date in English literature and only seven of those describe radiologic imaging features. We report radiologic findings of a bladder carcinosarcoma case, with bladder stone.

Method: Forty-five year old male presenting with gross hematuria and abdominal pain underwent suprapubic ultrasonography, contrast enhanced abdominal MRI and CT.

Results: Bladder wall thickening and a large bladder stone of 5.7 cm in diameter were detected on sonography. Afterwards, MRI showed an 83x43 mm sized, peripherally and heterogenously enhancing mass in the lumen of the bladder which was infiltrating anterior bladder and rectus abdominis muscle. The mass was isointense to muscle on T1WI, and heterogenously hyperintense on T2WI. 20 days later, contrast enhanced abdominal CT showed a 15 cm-sized peripherally enhancing mass in the lumen of the bladder, infiltrating anterior bladder wall and extending to the anterior abdominal wall. The patient underwent radical cystectomy, pelvic lymph node dissection and bladder substitution with bowel. After evaluation of pathological specimens, carcinosarcoma was diagnosed.

Conclusion: Carcinosarcoma is a high-grade aggressive neoplasm of the bladder. The tumor originates from the base of the bladder predominantly. The most common symptom is gross hematuria without pain. Carcinosarcomas are isointense to muscle on T1WI similar to transitional cell carcinomas. Unlike transitional cell carcinomas, carcinosarcomas have a heterogenous intensity on T2WI and show heterogenous contrast enhancement. Additionally, carcinosarcomas don’t show early arterial enhancement.

www.esur2013.org 146 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-26 - FDG UPTAKE OF PRIMARY RENAL MALIGNANCY IN CROSSED FUSED ECTOPIC KIDNEY Tatcı E. 1, Ozmen O. 1, Dadalı Y. 2, Gokcek A. 2, Gulgosteren S. 3, Bozkurt O. 4 Ataturk Chest Diseases and Thoracic Surgery Training and Research Hospital Nuclear Medicine Ankara- Turkey 1 Ataturk Chest Diseases and Thoracic Surgery Training and Research Hospital Radiology Ankara- Turkey 2 Ataturk Chest Diseases and Thoracic Surgery Training and Research Hospital Chest Disease Ankara-Turkey 3 Kecioren Training and Research Hospital Urology Ankara-Turkey 4

Objective: Crossed renal ectopia is a rare congenital anomaly with a reported incidence of 1:1.000 with male preominance. Primary malignancy in crossed ectopic kidney is uncommon. In the present study, we report a case of F-18 FDG uptake of renal malignancy associated with crossed renal ectopia. Method: A 49 years old male patient with dispnea was referred to PET/CT imaging for further evaluation of multiple nodules in both lungs that were detected on a CT scan. Results: The 18F-FDG PET/CT revealed crossed ectopic kidney on the left side with a 7x5x4.5 cm mass on its inferior pole. There were intense FDG uptake of renal mass (SUVmax: 6.83) and pulmonary nodules (SUVmax: 10.06). Patient was operated and ectopic right kidney was removed. The histopathologic examination of the renal mass was reported as grade 3 clear cell renal cell carcinoma. A percutaneous CT-guided core biopsy of pulmonary nodule revealed metastasis of renal malignancy. Conclusion: We reported a rare case of renal malignancy of crossed ectopic kidney.To our knowledge, this is the first report of renal malignancy of crossed ectopic kidney detected by FDG PET/CT. PET/CT may be useful in evaluation of renal masses.

P2-27 - FREE-HAND SONOELASTOGRAPHIC EVALUATION OF SCROTUM Pekindil G. 1, Müezzinoğlu T. 2, Gümüş B. 2 Celal Bayar University Radiology Manisa-Turkey 1 Celal Bayar University Urology Manisa-Turkey 2

Objective:to reveal sonoelastographic findings of many scrotal pathologies

Method: The thirty three cases who had detected scrotal pathology on scrotal ultrasonography, were prospectively evaluated with Free-hand sonoelastography using 5-9 Mhz lineer transducer. Sonoelastography was performed by manual compression of ultrasound probe (Antares). The strain data were converted into color scale images (elastogram-coloured with between red-hard to purple-soft tissues) and superimposed on B-mode images. Coloured elastogram images were qualitatively evaluated by describing qualitative stifness scores ranged between 0 (no increased stifness-purple) to 4 (whole lesion had increased stifness-red). The cases consisted of cysts of testes and epididymis (3), orchitis (5), acute and chronic epididymitis (4), malign testicular tumors (3),testicular lymphoma (1), tuberculosis (1), scrotal hematoma (1) and pyocele (1),leiomyoma (1), rhabdomyosarcoma (1), torsion of appendix testes (2), atrophic testes (2), retractile testes (7),infarcted testes (1).

Results:All cystic lesions showed no increased stifness and scores were 0 as expected. However infections and tumors of the testes demonstrated similar stifness scores between 2-4 and overlapping findings.

Conclusion:Although qualitative evaluation is the main advantage of free-hand sonoelastography, and there exist limited number of cases for each pathology in the study, our initial results show that infections and tumors (both benign and malignant) can not be clearly differentiated with free-hand sonoelastography in most of the cases.

P2-28 - FREE-HAND ELASTOSONOGRAHY OF BLADDER TUMORS Pekindil G. 1, Müezzinoğlu T. 2, Gümüş B. 2 Celal Bayar University Radiology Manisa-Turkey 1 Celal Bayar University Urology Manisa-Turkey 2

Objective: To reveal sonoelastographic findings of tumors of urinary bladder

Method: The thirteen cases who had detected intraluminal mass on ultrasonography of full bladder, were prospectively evaluated with Free-hand sonoelastography using 5-9 Mhz lineer transducer. Sonoelastography was performed by manual compression of ultrasound probe (Antares). The strain data were converted into color scale images (elastogram-coloured with between red-hard to purple-soft tissues) and superimposed on B-mode images. Coloured elastogram images were qualitatively evaluated by describing qualitative stifness

147 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY scores ranged between 0 (no increased stifness-purple) to 4 (whole lesion had increased stifness-red).All cases confirmed with pathological examination.

Results:All cases had intraluminal vegetative-polypoid mass, whereas one had diffuse-infitrative wall carcinoma. Twelve cases had bladder carcinoma ranged between 1-4 cm and one had ıntraluminal hematoma. Sonoelastography showed score 3-4 increased stifness in all malignant cases, whereas hematoma had score 0-1 stifness.Diffuse form of bladder cancer revealed score 2 on sonoelastography.

Conclusion:Our initial results show that all polipoid bladder cancers show inreased stifness scores 3-4, and although free-hand sonoelastography is a qualitative method, it can differentiate malignant intraluminal bladder masses from hematoma and can be of value in evaluation of bladder masses.

P2-29 - BLADDER CARCINOMA WITHIN A HERNIATED PORTION OF BLADDER US AND CT DEMONSTRATION Dikici A. 1, Nurili F. 1, Tutar O. 1, Yıldız Orman M. 1, Mihmanlı İ. 1, Kantarcı F. 1 Istanbul University Cerrahpaşa Medical Faculty Radiology Istanbul-Turkey 1

Objective:Bladder herniation into the inguinal canal is uncommon and seen in less than 4% of cases in which may include true bladder or a bladder diverticulum. Additionally, the presence of bladder carcinoma within a herniated portion of bladder is exceedingly rare, with less than 20 reports in the literature over the past 60 years. Computed tomography (CT) appears to be the best choice to outline the details of herniation and extent of neoplasm in which dictates surgery to be performed.

Method:We report a case of a uroepithelial cancer arising on the wall of massive inguinoscrotal bladder which first is detected by US and confirmed with CT imaging in 60 year-old man complaining of recurrent lower urinary infection and inguinal hernia . Ultrasonography of the inguinal region revealed a large cystic mass with protruding solid components that extents to the right hemiscrotum raised suspicion of bladder herniation. CT is requested for further analysis.

Results:CT demonstrated the bladder hernia, neoplasm and the depth of invasion and amount of a tumor elsewhere in the bladder and in the meantime has the advantage of being noninvasive.

Conclusion:Bladder herniation is rare entity. Cancer contained within these findings is even more uncommon, diagnosis and treatment presents a unique challenge. Pathologic and imaging diagnosis is crucial in determining the proper course of treatment. CT is a highly accurate method in the diagnosis and staging of bladder neoplasms arising in an inguinal hernia.

P2-30 - FREE-HAND ELASTOSONOGRAHY OF RENAL TUMORS Pekindil G. 1, Müezzinoğlu T. 2, Gümüş B. 2 Celal Bayar University Radiology m-Turkey 1 Celal Bayar University Urology Manisa-Turkey 2

Objective: To reveal sonoelastographic findings of renal tumors

Method: Twentyone cases suspected of renal tumor were prospectively evaluated with Free-hand sonoelastography using 5-9 Mhz lineer transducer. Sonoelastography was performed by manual compression of ultrasound probe (Antares). The strain data were converted into color scale images (elastogram-coloured with between red-hard to purple-soft tissues) and superimposed on B-mode images. Coloured elastogram images were qualitatively evaluated by describing qualitative stifness scores ranged between 0 (no increased stifness-purple) to 4 (whole lesion had increased stifness-red).All cases confirmed with pathological examination.

Results:Fifteen cases had renal cell carcinoma ranged between 3-8cm, and rest of the cases had renal lymphoma (1),pararenal absscess (2), renal absscess (1), renal infarctus (1), complicated cyst (1). Since the depth of transmission is limited to 12-13 cm, two cases with obesity and one case with deeply located cancer could not be evaluated by lineer transducer. However all other cases (13) with renal carcinoma showed increased stifness scores between 2-4, whereas score 0-1 detected in case with Burkitt lymphoma of kidney.

www.esur2013.org 148 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Sonoelastography revealed score 3-4 in a case with partially infarcted renal parenchyma. Absscesses showed score 1-3, additionally sonoelastography showed score 3 increased stifness of adjacent tissues.

Conclusion: This initial study has disadvantages of free-hand sonoelastography such as being qualitative and limited penetration of linear transducers,however it is most avaiable form of sonoelastography. Although both renal cancers and absscesses may show increased stifness on sonoelastography, sonoelastography can be useful in diagnosis by revealing additional increased stifness of adjacent tissues in absscess.

P2-31 - METASTATIC LEFT RENAL TUMOR FROM HEPATOCELLULAR CARCINOMA A CASE REPORT Farg H. 1, El-Sorougy A. 1, Abou-Bieh E. 1, El-Diasty T. 1 Urology & Nephrology Center Radiology Mansoura-Egypt 1

A 25 -year-old female patient with past history of excised hepatic mass (2 x 2cm) from the left liver lobe and the post operative histopathology was hepatocellular carcinoma (HCC) 4 years ago. During routine ultrasound examination revealed large left renal mass. Computed tomography was done revealing multiple small hepatic focal lesions and left renal parenchymal tumor, so, CT guided needle biopsy from the renal mass was done revealing that it is a metastatic from HCC.

P2-32 - MAGNETIC RESONANCE IMAGING FINDINGS OF INFLAMMATORY MYOFIBROBLASTIC TUMOR OF URINARY BLADDER Acu B. 1, Kurtuluş E. 1, Gökçe E. 2, Beyhan M. 2, Kara T. 1 Osmangazi University Medical Faculty Radiology Eskisehir-Turkey 1 Gaziosmanpasa University Medical Faculty Radiology Tokat-Turkey 2

Objective:Inflammatory myofibroblastic tumor (IMT) is a rare bladder tumor which is extremely difficult to distinguish from malignant tumors clinically, radiologically and also histopatologically that may misdiagnosed. We aim to present a MRI findings of a case of IMT of the urinary bladder and its clinical presentation and diagnosis.

Method: A 27 year old female presented with painless hematuria,clots in urine in the past one month. The patient referred to us from Urology department.At the time of admission the physical examination findings were unremarkable.Blood chemistry values were in normal limits.The patient examined with MRI.

Results: The patient investigated with pelvic MRI, which showed a broad based, contrast enhanced mass with heterogeneous signal intensity that is protruding into the lumen from anterior wall bladder.The patient underwent transurethral resection of the lesion.The histopathological examination reported as IMT.

Conclusion: IMT is a rare mesenchymal tumour presented with a mass that mimic malignancy and composed of spindle cells mixed with variable amounts of extracellular collagen, lymphocytes and plasma cells.IMT can be seen at any anatomical location.The symptoms and manifestations of IMT vary depending on the anatomical location of the lesion. In IMT of the bladder,painless hematuria with or without clots from exophytic and ulcerated lesions is the most common initial manifestation.The main criteria for diagnosis of IMT is the histopathologic reported as spindle myoepithelial proliferation and lymphocytic infiltrate.Although the definitive diagnosis of IMT is histopathologically, radiological imaging is important for the diagnosis and the treatment when choosing and planning the surgery.

P2-33 - A HUGE SCROTAL MASS; LIPOMA OR LIPOSARCOMA Celdirme E. 1, Gürel S. 1, Metin A. 2, Yilmaz F. 3 Abant İzzet Baysal University Radiology Bolu-Turkey 1 Abant İzzet Baysal University Urology Bolu-Turkey 2 Abant İzzet Baysal University Pathology Bolu-Turkey 3

Objective: We aim to present the diagnostic challenge of a slowly growing lipomatous scrotal mass and its demonstrative findings at ultrasonography (USG) and magnetic resonance imaging (MRI).

Methods:47-year-old male patient who presented with painless, slowly growing giant scrotal mass. Scrotal Gray scale and Doppler US and contrast enhanced dynamic testis MRI were performed.

149 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Results:US showed an extratesticular, heterogeneous, isoechoic to subcutaneus fat, mildly peripherally vascularized mass. MRI proved that, it neither originated from testis nor spermatic cord. Mass was larger than 10 cm. Compared to subcutaneous fat it was homogeneously hyperintense on both T1 – and T2 weighted sequences., and its signal was suppressed homogenously at fat saturated sequences and showed no remarkable enhancement. The final radiological diagnosis was capsulated lipoma, not a liposarcoma, that was proved by histopathological examination as well.

Conclusion:Lipomas are very frequent benign mesenchimal neoplasms and can be seen anywhere around body but is rare at perineum. Most of paratesticular lesions are non-neoplastic and primary paratesticular solid neoplasms are rare. Scrotal lipoma is the most common benign neoplasm of the paratesticular tissues. They are usually asymptomatic other than slowly growing mass, and patients can be at any age. Radiological findings are; at US; homogeneous hyperechogenity, CT ; homogeneous hypodensity, and MRI lipoma is uniform and isointense with fatty tissue at all sequences, and suppressed in fat-saturated images, which confirms the diagnosis. Transformation to liposarcoma is very rare but possible. So a radiologist should be aware if the mass contains the futures of a liposarcoma.

P2-34 - RADIOLOGIC FINDINGS OF RENAL INFLAMMATORY PSEUDOTUMOR Erbay G. 1, Karadeli E. 1, Koc Z. 1 Baskent University Radiology ADANA-Turkey 1

Objective: Inflammatory pseudotumors, also known as inflammatory myofibroblastic tumors, are uncommon benign tumors of unknown etiology. In the urogenital tract, inflammatory pseudotumor usually affects the urinary bladder or the prostate.We present CT and MRI findings of 63-year-old man patient. Methods: A 63 -year-old man presented with enfection in the left hip prosthesis was evaluated with CT and MRI. Results: Abdominal CT revealed exophytic and intrarenal tumor on the left kidney (13 cm in size). The kidney was displacement laterally by tumor. There were multiple nodules in the perirenal fatty tissue. At abdominal MRI, tumor with lobule contours on the left kidney (13x13x11 cm in size) was hypointense on T1-weighted images, mild hyperintense on T2-weighted images, lesser enhancement than normal kidney on postcontrast MRI images.On diffusion-weighted images, high ADC levels according to normal kidney were found. Bilateral perirenal multiple nodules were the same signal intensity with primary tumor .The tumors with high fibrous content and/ or tumors with low cell consistency were considered in the differential diagnosis. Histopathological examination resulted in the lesion being diagnosed as an inflammatory pseudotumors. Conclusion: Inflammatory pseudotumor is an extremely rare neoplasm. The preoperative diagnosis remains difficult, despite progress in medical imaging and often requires surgical exploration. Myofibroblast, fibroblast, histiocytosis, plasma cell proliferation are seen on histopathological examination. Renal cell carcinoma, inflammatory fibrosarcoma, malignant fibrous histiocytoma, myxoid leiomyosarcoma for malignant diseases and angiomyolipoma, xanthogranulomatous pyelonephritis, plasma cell granuloma for benign diseases are considered in the differential diagnosis.

P2-35 - DWI IN THE DIFFERENTIATION AND CHARACTERISATION OF RENAL MASS LESIONS Kilicoglu Z. 1, Kis N. 2, Düzkalir H. 3, Agacli M. 4, Simsek M. 1 Haydarpasa Numune Education and Research Hospital Radiology Istanbul-Turkey 1 Bitlis State Hospital Radiology Bitlis-Turkey 2 Mus State Hosspital Radiology Mus-Turkey 3 Zonguldak Maternity Hospital Radiology Zonguldak-Turkey 4

Objective: Characterisation and differentiation of kidney masses with ADC values of DWI imaging

Method: 54 cases with mass lesions in the kidney were included in the study. Following routine abdominal MRI on a 1,5T device, DWI with b=0, b=500 and b=1000 were obtained. ADC maps were used for measurement and values of mass lesions were compared with ipsilateral normal renal areas. Pathological results were compared with ADC values and a ROC analysis was performed.

Results: 72 lesions of 54 patients (35 males, 19 females) were evaluated. Mean age was 59.5±15.7 years (range 26-86 years). 40 lesions were benign, including 19 Bosniak type 1 cysts, 12 type 2 cysts, 3 oncocytomas and 6 angiomyolipomaas, while 32 malignant lesions comprised of 31 renal cell carcinomas and one transitional cell carcinoma. ADC valueas obtained from b=500 and b=1000 were similar in sensitivity and spesificity. Benign lesions had significantly high ADC values compared with malignant lesions ( p<0,01).

Subgrouping of 31 renal cell carcinomas was: 22 clear cell RCC, 7 papillary RCC and 2 chromofob RCC. Comparing clear cell RCC with the others revealed that at b=500, ADC values were significantly higher (p<0.05) and a cutoff of 0.99x10-3 mm2/s differentiated clear cell RCC with good sensitivity and spesificity (91% and 56% respectively).

Conclusion: DWI is effective in the differentiation of benign from malignant renal masses and DWI with b=500 may provide subgrouping of renal cell carcinomas.

www.esur2013.org 150 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-36 - PELVIC PLASMACYTOMA IN AN HIV POSITIVE PATIENT Kaplanoglu H. 1, Parlak S. 2, Altın L. 2, Kaplanoglu V. 2, Deveer M. 3 Dışkapı Yıldırım Beyazıt Education and Research Hospital Radiology Ankara-Turkey 1 Numune Education and Research Hospital Radiology Ankara-Turkey 2 Mugla University Faculty of Medicine Radiology Mugla- Turkey 3

Plasma cell tumor incidence is high in HIV (+) patients. These tumors arises in younger ages if HIV accompany and this association gets disease more aggressive. HIV (+)57 years old male patient was referred to our hospital due to trombocytopenia. In physical examination, petechial hemorrhages were seen in different parts of his body. Polymerase chain reaction (PCR) showed 67 copies/ml of HIV RNA in laboratuary tests. Other laboratuary tests showed haemoglobin 11,5 g/dL, leucocyte 3880/μL, thrombocyte 131000/μL, total protein 89 g/L, albumin 29 g/L, IgG 3980 mg/dL (normal values 791 – 1643 mg/dL), lactate dehydrogenase 605 U/L, alkaline phosphatase 115 U/L, β-2 microglobulin 4,29 mg/L, creatinine 2,2 mg/d L and erythrocyte sedimentation rate 80 mm/hour. Monoclonal gamma peak was seen in serum protein electrophoresis. Left shift was determined in peripheral blood smear. Heterogenous hyperechoic 13x10x9 cm sized solid mass was seen in pelvic region contiguous to rectum in abdominal sonography. Soft tissue mass filling the whole pelvis and presacral area, was scanned on computed tomography. Magnetic resonance imaging was performed to demonstrate relationship between mass and pelvic organs. There was no distinction between mass and bladder, rectum, prostate. The diagnosis was plasmositoma after tru-cut biopsy. The tumor council decided the mass as unresectable and they planned chemotherapy and radiotherapy in treatment. Extramedullary plasmacytoma in HIV(+) patients located in the pelvic region is limited to a few cases in the literature. Our aim is to present this rare case in the light of radiologic findings and literature.

P2-37 - LYMPHATIC SPREAD IN UROGENITAL PELVIC MALIGNANCIES Boussalah M. 1, Benmoussa R. 1, Touil N. 1, Kacimi O. 1, Chikhaoui N. 1 Ibn Rochd Teaching Hospital Emergency Radiology Casablanca-Morocco 1

Objectives: Detection of lymph nodes metastases is crucial for the accurate staging of urogenital pelvic malignancies. It is important for clinical management and is frequently an independent prognostic factor. We aim to describe the anatomy and nomenclature of the iliopelvic and para-aortic lymph nodes and to outline common pathways of metastasis from tumors of the urogenital system to these regional nodes.

Methods: We describe anatomy and nomenclature of pelvic lymph nodes and outline common pathways of metastasis from tumors of the urogenital system based on a Computed Tomography and/or MRI pictorial review.

Results: Urogenital pelvic cancers commonly spread to iliopelvic or retroperitoneal lymph nodes by following pathways of normal lymphatic drainage from the pelvic organs. The most likely pathway of nodal spread depends on the tumor location and whether surgery or other therapy has disrupted normal lymphatic drainage from the tumor site; knowledge of both factors is needed for accurate disease staging. At present, lymph node status is most often assessed with standard anatomic imaging techniques such as computed tomography or magnetic resonance imaging. However, the detection of nodal disease with these techniques is reliant on lymph node size and morphologic characteristics, criteria. Functional imaging techniques, such as diffusion-weighted MR imaging and positron emission tomography, may allow a more accurate nodal assessment based on molecular or physiologic activity.

Conclusion: Knowledge of the anatomic pathways by which urogenital tumors spread may facilitate identification of the most likely sites of nodal involvement, helping improve nodal assessment.

151 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P2-38 - A COMPUTED BASED APPROACH ON ADRENAL MASS Boussalah M. 1, El Yaagoubi M. 1, Siwane A. 1, Lezar S. 1, Essodegui F. 1 Ibn Rochd Teaching Hospital Central Radiology Casablanca-Morocco 1

Objectives: Multidetector Computed Tomography (MDCT) is an integral tool in the assessment of adrenal masses. Dedicated adrenal CT is performed for a range of indications, including hormonal abnormalities suggestive of a functional adrenal mass and adrenal cancer staging. We aim to provide for radiologists a pictorial review of cases met in our department, to have an understanding of the published data that guide protocol design and image interpretation in adrenal masses.

Methods: We describe MDCT finding in 15 patients with adrenal mass.

Results: Adenomas typically demonstrate rapid washout in two patients finding. Adrenocortical carcinoma typically has an RPW of less than 40%; however, large size and heterogeneity are more reliable indicators of the diagnosis than are washout values, which were found in 4 cases. Washout characteristics in 4 cases of pheochromocytoma are variable; in conjunction with high levels of dynamic enhancement. Myelolipoma appear as well-defined masse with variable quantities of fat and soft tissue, shown in one case. Finally, after contrast material administration, metastases usually demonstrate slower washout on delayed images than do adenomas in 2 cases.

Conclusion: The adrenal gland is involved by a range of neoplasms, including primary and metastatic malignant tumors; however, the most common tumor detected is the incidental benign adenoma. Although, the use of cross-sectional imaging, us MDCT will not always yield a definitive diagnosis, attention to these findings provides a road map to guide image interpretation.

P2-39 - THE ROLE OF LEARNING CURVES AS A FUNCTION OF THE EXPERTISE IN THE PROSTATE MRI Barchetti F. 1, Ciardi A. 1, Catalano C. 1, Panebianco V. 1 Sapienza University of Rome Department of RAadiology Rome-Italy 1

Purpose: To evaluate the changing of sensitivity in detecting prostate cancer (PC) by meansof Multiparametric-MRI (Mp-MRI) examination assessing the increasing of learning curves with the advance of personal experience.

Materials and Methods: 900 patients who underwent from january 2010 to february 2013 a Mp-MRI examination of the prostate gland for raising PSA serum levels were independently retrospectively evaluated by the same 2 readers who together previously observed the exams. Reader A (R.A) was an experienced radiologyst in uro-genital field with 10 years of experience, and reader B (R.B) was a radiology resident with 3 years of experience.

Results: 170 patients out of 900 were originally assessed negative for the presence of morpho-functional changings both in peripheral zone (PZ) and central zone (CZ). R.A in 69 out of 170 patients detected subsequently an altered focus and 2 further suspected areas in 30 men, while R.B detected a suspected lesion in 63 patients (K = 0.754, P = 0.034). 330 patients out of 900 in the first reading were considered positive for a focus of morpho-functional changings of MRI patterns: in the second reading R.A discovered a further area of suspected malignancy in 157 patients, while R.B in 104 patients detected a further lesion (K = 0.684, P = 0.026). In 350 patients out of 900 initially were estimated two suspected malignant zones: in the second reading R.A discovered a

www.esur2013.org 152 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 3 - Infertility

P3-01 - SCROTAL ULTRASOUND ELASTOGRAPHY IN DIFFERENTIATION OF THE VARICOCELE- INDUCED TESTICULAR DYSFUNCTION Yildirim D. 1, Tutar O. 2, Nurili F. 2, Bozkurt H. 3, Cirakoglu A. 4 Centermed Advanced Imaging Center Department of Radiology istanbul-Turkey 1 Istanbul University, Cerrahpasa Medical Faculty Hospital Department of Radiology Istanbul-Turkey 2 Izmir Bozyaka Education and Research Hospital Hospital Department of Urology Izmir-Turkey 3 Kasimpasa Military Hospital Department of Radiology Istanbul-Turkey 4

Objectives: To assess the ability of ultrasound elastography (USE) in determination of the testicular dysfunction at the affected site of the varicocele.

Methods:In this study 12 male patients (mean age 27 y/o), who were investigated for infertility included. All cases were investigated with US, Doppler US and USE that carried out in our unit. Elasticity images of the both testicles for each cases obtained in similar ways and with same US unite by recording the strain based maps obtained at same settings (QF:75). In color coding harder tissues adjusted as red and soft tissues as green. And dominant patterns on color maps were compared with each other.

Results:In cases in which 2 color distribution pattern were detected according to strain based color maps images; homogenous red staining was classified as pattern 1 and mix type (peripherally red, centrally green) staining was classified as pattern 2. In 9 of 12 cases, left testicle which was affected by varicocele characterized with pattern 2 and 2 cases with normal right testicle characterized with pattern 2. USE imaging all other right testicles (n=10) and only 3 of left testicles of cases which were affected by varicocele, were characterized as pattern 1.

Conclusions: Varicocele induced testicular dysfunction and atrophy can be differentiated with USE without any complicated measurement, up to 80% accuracy. If this preliminary study expanded into larger patient series and include cases from the all varicocele grades, it can open a brand and prosperous perspectives for diagnosis of varicocele.

P3-02 - BILATERAL SEMINAL VESICLE AGENESIS CASE PRESENTATION

Keskin S. 1, Keskin Z. 2, Poyraz N. 1, Ödev K. 1 Necmettin Erbakan University, Meram School of Medicine Radiology Konya-Turkey 1 Konya Training and Research Hospital, Konya Radiology Konya-Turkey 2

Objective: Bilateral seminal vesicle agenesis is a rare anomaly and is the result of a developmental disorder of the mesonephric duct. We present radiologic findings in a patient with bilateral seminal vesicle agenesis.

Method: A 26-year-old man was admitted to the urology department with ejaculation disorder. Transrectal ultrasound (US) and enhanced pelvic magnetic resonance imaging (MRI) were performed.

Results: In US, Both seminal vesicles were not found in periprostatic area. Pelvic MRI confirmed the absence of seminal vesicles bilaterally.

Discussion: Bilateral seminal vesicle agenesis is a rare anomaly. Transrectal US and MRI can be used for diagnosis.

153 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P3-03 - SCROTAL ULTRASONOGRAPHIC FINDINGS IN YOUNG MEN WITH CONGENITAL HYPOGONADOTROPIC HYPOGONADISM Artas H. 1, Saglam M. 1, Kocak O. 1, Taslıpınar A. 2, Karaman B. 1, Colak F. 1 Gulhane Military Medical Faculty Department of Radiology ANKARA-Turkey 1 Gulhane Military Medical Faculty Department of Endocrinology ANKARA-Turkey 2

Objective : Congenital hypogonadotropic hypogonadism(CHH) is characterised by low gonadotropin and sex steroid levels in the absence of anatomical or functional abnormalities of the hypothalamic-pituitary- gonadal axis. The aim of this study was to evaluate and determine the scrotal sonographic findings and the frequency of the scrotal pathologies in patients with CHH.

Method :A total of 73 newly diagnosed young CHH patients who had undergone scrotal ultrasound were enrolled in this study

Results:73 patients’ age were ranged between 18 and 24 years (20,5 ± 1.5 years). The mean ultrasonographic testicular volumes in this study were 2.06±1,85 mL ( 0,37-6,83 mL) at right testes, and 2,06±1,78 mL (0,41-6,84 mL) at left testis. At sonographic examination, 29 (39.7%) of 73 patients had no pathologic abnormalities of the scrotal contents except small testiculary volume. We found testicular microlithiasis in 15 patients (20.5%), epididymal cyst in 12 patients (16.4%), varicocele in 11 patients (15.1 %), scrotal calculi in 9 patients (12.3%), undescended testes located within the inguinal canal in 3 patients (4,1%), tunica albuginea cyst in 2 patients (2.7%), hydrocele in 1 patient (1.3%), and hyperechogenic small mass lesion in 1 patient (1,3%). For 3 patients, testes were not found within inguinal canal or intraabdominal regions (4,1%).

Conclusion:In our study, the frequency of scrotal pathologies in patients with CHH was higher than the normal population. Therefore, we think that patients with CHH should be screened and followed with scrotal ultrasound.

P3-04 - ENDOMETRIAL THICKNESS EVALUATION BY THREE DIMENSIONAL TRANSVAGINAL ULTRASOUND AS A PREDICTOR OF PREGNANCY OUTCOME IN IVF PATIENT.

Salamati m. 1, Ahmadi f. 1, Akhbari f. 1, Irani s. 1 Department of Reproductive Imaging at Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR imaging Tehran-Iran 1

Objective: To evaluate the role of endometrial thickness on the day of HCG (human chorionic gonadotropin) administration in in-vitro fertilization (IVF) outcome.

Method and materials: Endometrial thickness of two hundred and seven patients were evaluated in this prospective study.Transvaginal ultrasound assessment ofendometrial thickness was performed on the day of HCG administration.

Result: The endometrial volume was divided to 3 group:≤7mm(Group 1),8 14mm(Group2), ›14mm(Group3). Positive pregnancy in group 1 ,2 and 3 were16.7%,36.1 and 46.2% respectively.

Conclusion: There is no statistical significant relationship between endometrial thicknes on the day of hCG administration and predicting pregnancy outcome in ART cycle (According to chi-square test which was obtained by the data).However comparing 3 ,patients with endometrial thickness of ›14mm(Group3) has shown the better pregnancy rate (46.2%).

www.esur2013.org 154 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P4-01 - RETROAORTIC AND CIRCUMAORTIC LEFT RENAL VEINS VARIATION DETECTED WITH 120 100 & 80 KVP 64 MULTIDETECTOR COMPUTED TOMOGRAPHY UROGRAPHY PROTOCOLS Al-Amin M. 1, Hadjidekov G. 2, Diakov I. 3 University Hospital Alexandrovska Department of diagnostic imaging Sofia-Bulgaria 1 Hospital Lozenets Department of Radiology Sofia-Bulgaria 2 National Centre of Radiobiology and Radiation Protection Sofia- Bulgaria 3

Objective: The most common anomalies of the left renal venous system are the circumaortic and retroaortic renal vein. Knowledge of the renal venous anomalies may greatly contribute to the success of surgical, invasive and radiological procedures of the retroperitoneal region and our goal is to present them using protocols with lower kVp and eff mAs keeping other scanning parameters unchanged.

Method: There are different protocols based on the principles of ALARA. We have used three low-dose protocols of the study with no special preparation for the patients. We use three phases and late excretory one, after the introduction of contrast medium, using a single – bolus technique. Reconstructions are made on Maximim intensity projection and on Volume rendering.

Results: There are significant differences between the protocols up to 63 % reduction in effective dose which is estimation of radiation risk and up to 66% dose reduction in measurable quantities CTDI and DLP between the normal and ultra-low-dose protocol. At the same time the images obtained with the new low- dose protocols have maintained their quality and shows the same diagnostic results.

Conclusion: Knowledge of the renal vascular anatomy is important for the surgical planning. As the radiation dose in an important issue, using low-dose and ultra-low-dose protocols of research we save the image quality and reduce the radiation dose at the same time.

P4-02 - PREVALENCE OF CONTRAST INDUCED NEPHROPATY (CIN) IN PREEMPTIVE LIVING RENAL DONOR RECIPIENTS AFTER ENHANCED CT WITH CIN PROPHYLAXIS. Sebastià C. 1, Peri L. 2, Blasco M. 3, Buñesch L. 1, Musquera M. 2, Nicolau C. 1 Hospital Clinic Radiology Barcelona-Spain 1 Hospital Clinic Urology Barcelona-Spain 2 Hospital Clinic Nefrology Barcelona- 3

The aim of this study is to describe the prevalence of CIN and the need for dialysis in preemptive living renal donor recipients after enhanced computed tomography (CT) with CIN prophylaxis. P4-03 - CALCIFIED RENAL ARTERY ANEURYSM RADIOLOGIC FINDINGS OF A RARE CASE Çeltikçi P. 1, Dilli A. 1, Fırat H. 1, Hekimoğlu B. 1 Ankara Yıldırım Beyazıt Training and Research Hospital Radiology Ankara-Turkey 1

Objective: Renal Artery aneurysms (RAA) are rare cases, occuring approximately 0.09% of the population and are generally diagnosed incidentally. Most cases remain asymptomatic, however there could be serious clinical presentations as aneurysm rupture, peripheral emboli or arterial thrombosis. Hypertension and hematuria are reported in most of the cases. We aim to present radiological findings of a calcified renal artery aneurysm.

Method: Conventional radiography (CR), gray scale and color Doppler ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) were used to diagnose the case.

Case and Results: 75 year old female patient admitted to urology outpatient clinic with nonspesific urinary symptoms. On CR, a radioopacity was present located on right kidney hilus level, 2 cm in diameter and peripherally calcified in egg-shell form. Gray scale ultrasonography revealed a peripherally hyperechogenic cystic lesion showed aliasing artifact on Color Doppler US caused by turbulant flow and pulsatile arterial flow pattern on spectral analysis. Lesion was evaluated as a calcified renal artery aneurysm and an abdominal CT with intravenous contrast administration was performed to search for possible related pathologies. CT revealed an aneurysm of the right renal artery with contrast enhanced lumen and peripherally calcified wall. On MRI, T1 weighted and T2 weighted images demonstrated a round lesion with no peripheral signal. Contrast enhanced MR angiography confirmed the lesion as a renal artery aneurysm.

Conclusion: Although usually being asymptomatic, it is important to establish proper radiological interpretation and algorhytm for renal artery aneurysms which can present with mortal complications beside nonspesific symptoms.

155 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P4-04 - RENAL ARTERY ANEURISM OF CALCIFIED NATURE RADIOLOGIC FINDINGS OF A RARE CASE Dilli A. 1, Celtikci P. 1, Fırat H. 1, Hekimoglu B. 2 S.B. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 1 S.B. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Radyoloji Kliniği Radiology Ankara-Turkey 2

Objective: Renal Artery aneurisms (RAA) are rare cases, occurring approximately 0.09% of the population and which are generally diagnosed incidentally. Most cases remain asymptomatic, however there could be serious clinical presentations such as aneurism rupture, peripheral emboli or arterial thrombosis. Hypertension and hematuria are reported in most of the cases. We aim to present radiological findings of a calcified renal artery aneurism.

Method: Conventional radiography(CR), gray scale and color Doppler ultrasonography(US), computed tomography(CT) and magnetic resonance imaging (MRI) were used to diagnose the case.

Results: On CR, a radioopacity was present which is located on right kidney hilus level, in 2 cm diameter and peripherally calcified in egg-shell form. Gray scale ultrasonography revealed a cystic lesion located at the renal hilus, which had an hyperechogenic wall with acoustic shadowing that indicated peripheral calcification. Color Doppler US showed aliasing artifact caused by turbulant flow and pulsatile arterial flow pattern on spectral analysis. Lesion was evaluated as a calcified renal artery aneurism and an abdominal CT with IV contrast administration was performed to search for possible related pathologies. CT revealed an aneurism of the right renal artery with contrast enhanced lumen and peripherally calcified wall. On MRI, T1 weighted and T2 weighted images demonstrated a round lesion with no peripheral signal. Contrast enhanced MR angiography confirmed the lesion as a renal artery aneurism.

Conclusion: Although usually being asymptomatic, it is important to establish proper radiologic interpretation and algorhytm for renal artery aneurisms which can present with mortal complications beside nonspecific symptoms.

P4-05 - COMPARSION OF RENAL RESISTIVE INDEX IN KIDNEYS OF PATIENTS BETWEEN TUBELESS AND STANDARD NEPHROLITHOTOMY Başara I. 1, Akın Y. 2, Gülmez H. 3 Dokuz Eylül Universty Faculty of Medicine Radiology Izmir-Turkey 1 Erzincan Universty Faculty of Medicine Urology Erzincan-Turkey 2 Başkent Universty Faculty of Medicine Family Medicine Ankara-Turkey 3

Objective: To compare renal injury and vasculary resistance between standard and tubeless percutaneous nephrolithotomy (PCNL) in patients operated for kidney stone by using colored Doppler ultrasonography (CDU).

Methods: All consecutive PCNLs were evaluated between 2009-2011. The patients which access to the kidney were provided in lower pole and who visited our outpatient clinic regularly were enrolled study. Patients were who were performed standard PCNL were included in Group 1, patients who were performed tubeless PCNL were included in Group. CDU was performed to all patients for evaluating resistive index (RI), parenchymal thickness and parenchymal echogenity before operation, after operation as early postoperative and midterm postoperative period. Statistical significant p was accepted p<0.05.

Results: Mean 47.18±1.3 years. The mean follow-up was 10.71±1.2 months. There was no statistical difference for mean age, body mass index, stone burden, serum creatine, hemoglobin, delta hemoglobin, complications, urinary culture, stone free rate between groups. Comparison before and early postoperative operation, there were differences in groups for CDU, including RI, parenchymal thickness. There was increase for RI and decrease for parenchymal thickness in midterm follow-up period when compared RI before operation in lower pole of kidney which were operated. There was no difference for renal echojenity in CDU in groups between before and mid-term follow-up period.

Conclusion: PCNL is minimally invasive and safe procedure for kidney stones sized bigger than 2 cm. Tubeless PCNL was successful as standard PCNL, provided shorter hospital stay than standard PCNL and less damage to kidney in early follow-up period.

www.esur2013.org 156 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P4-06 - LEFT INFERIOR VENA CAVA AND RIGHT RETROAORTIC RENAL VEIN UNISION CT AND MRI FINDINGS OF A RARE CASE Fırat H. 1, Dilli A. 1, Çeltikçi P. 1, Ayaz Ü. 2 S.B. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 1 S.B. Mersin Kadın Doğum ve Çocuk Hastalıkları Hastanesi Radiology Mersin-Turkey 2

Objective: There may be several variations of the inferior vena cava (IVC) and renal vein. The most common variations of the IVC are double IVC and rarely left IVC. The most common variations of renal veins (RV) are multiple renal veins, and less frequently retroaortic and circumaortic renal vein. We aimed to present a rare case of left IVC and right retroaortic renal vein association with CT and MRI findings.

Method: 63-year-old man was evaluated with abdominal CT scan and MRI because of a lesion which was described during ultrasonography examination.

Result: In contrast-enhanced abdominal CT scan and MRI examination, IVC showed an upward trend from the left side of the abdominal aorta. The right renal vein joins the IVC, showing retroaortic extension. Above that IVC passes behind the aorta showing retroaortic course, reaching out to the right side.

Conclusion: Generally there is no clinical significance of the left sided IVC. However, it can be misdiagnosed as left paraaortic lymphadenopathy and aortic aneurysm surgery can be complicated by this. Although the renal vein variations are usually asymptomatic, it can be symptomatic by renal vein’s compression between the aorta and vertebral body which is called posterior nutcracker sydrome. The syndrome manifests as varicocele, left ovarian congestion, and may cause hematuria, lomber pain, and ureteropelvic junction obstruction in both. The diagnosis of renal vein variations are important because it may cause undesirable complications such as hemorrhage in patients undergoing retroperitoneal surgery, nephrectomy or it may even result in death.

P4-07 - IDIOPATHIC RENAL ARTERIOVENOUS MALFORMATION Bayarogullari H. 1, Görür S. 2, Atci N. 1, Yeral H. 1, Davran R. 1, Karazincir S. 1 Mustafa Kemal University Radiology Hatay-Turkey 1 Mustafa Kemal University Urology Hatay-Turkey 2

Congenital renal arteriovenous malformation(AVM)’s are very rare conditions. They can be congenital or acquired. The acquired AVMs are usually result from trauma, inflamations or percutaneous procedures such as renal biopsy. The prevalence of congenital renal AVM is less than 0.04% and for 3%-5% of all renal AVMs. They rarely manifest in elderly people and more common in women. They may be asymptomatic, but the most common symptom of renal AVMs are hematuria. The other symptomps of AVMs are flank pain, hypertension, cardiac failure and abdominal pain. Hematuria may require open surgery or arterial embolisation for preserving renal parencyma. Congenital renal AVMs consist of multiple tortuous, dilated vessels and can mimic renal cell carsinoma. A 67 year old female patient was referred to our hospital with left kidney mass. She presented us with no urinary symptom. On ultrasound examination calcifying multilocule cystic mass found in the left kidney. Color doppler findings promted us to a suspected renal arteriovenous malformation. Multidetector computed tomography (MDCT) performed after contrast agent injection and renal AVM is cleary seen as dilated, tortuous vein related with renal artery and vein. Compared with ultrasound, MDCT improves visualization of the anatomy and it helps surgeons in planning operation. When you see any cystic lesion at ultrasound examination, you must memorize renal AVMs.

P4-08 - MDCT IN THE EXCLUSION OF RENAL DONORS Chingkoe C. 1, Zasowski A. 1, Pace K. 2, Kirpalani A. 1, Colak E. 1 St. Michael’s Hospital, University of Toronto Departments of Medical Imaging Toronto-Canada 1 St. Michael’s Hospital, University of Toronto Departments of Medical Urology Toronto-Canada 2

Objective: To review MDCT findings that lead to exclusion of potential donors from a live renal donor transplantation program.

Method: Preoperative CT examinations of 529 consecutive potential renal donors were retrospectively reviewed. CT reports from the initial interpretation and multidisciplinary donor assessment conference were

157 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY reviewed. Incidental findings were categorized as abnormalities of the renal parenchyma, vascular system, or collecting system. Extra-renal findings were categorized as malignancy, infection, inflammatory conditions, vascular abnormalities, or other. Imaging findings that resulted in the exclusion of patients from our renal transplantation program were recorded.

Results:A total of 57 (10.7%) patients were excluded from our renal transplantation program on the basis of imaging findings. The most common causes for donor exclusion were nephrolithiasis (n=23), supernumerary arteries (n=18), short pedicles (n=6), and supernumerary veins (n=4). Other causes for exclusion included cortical scarring (n=3), nephrocalcinosis (n=3), renal malignancy (n=2), polycystic kidney disease (n=2), complex cysts (n=2), FMD (n=1), renal arterial aneurysm (n=1), calyceal diverticulum (n=1), and hydronephrosis (n=1).

Conclusion:Pre-operative renal donor CT examinations can identify reasons for renal donation exclusion, and direct proper investigations and management of incidental findings.

www.esur2013.org 158 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 5 – Interventional Procedures

P5-01 - THE SEVERE HEMORRHAGIC COMPLICATIONS AFTER PERCUTANEOUS NEPHROLITHOTOMY Yağcı B. 1, Zümrütbaş A. 2, Koçyiğit A. 1 Pamukkale University Hospital Radiology Denizli-Turkey 1 Pamukkale University Hospital Urology Denizli- Turkey 2

Purpose:To present angiographic findings and interventional radiological management of the severe hemorrhagic complications of percutaneous nephrolithotomy (PNL).

Material and Methods:We retrospectively reviewed the data of patients who had undergone PNL for removal of renal calculi at our institute between 2008 January and 2012 December. Postoperative patients with gross hematuria, hypotension, and decreasing hematocrit that does not respond to conservative management underwent renal angiography and subsequent selective embolization.

Results: Of the 533 patients, 5 (0.94%) required angiography and embolization for bleeding control. The mean time to the onset of severe hemorrhage was 9.6 days (range, 6 to 17). Renal arteriography revealed arteriovenous fistula (AVF) in 1, two separate lesions (a lacerated renal segmental artery with active contrast extravasation and arteriocalyceal fistula, and another segmental artery with AVF) in 1, a combination of active contrast extravasation and AVF in 1, and pseudoaneurysm in 2 patients. Superselective catheterisation of the injured vessels was performed with a coaxial microcatheter and 0.018-inch fibered platinum microcoils (mean number, 3.8; range, 1 to 6) were used to occlude the lesions completely. Successful embolization was achieved without complications in all patients and none required a postprocedural blood transfusion.

Conclusion:Massive hematuria is a rare complication of PNL that can be successfully managed with selective embolization.

P5-02 - BILATERAL HYDRONEPHROSIS IN ADULTS TO DO OR NOT TO DO PERCUTANEOUS NEPHROSTOMY Sung D. 1, You S. 1, Han N. 1, Park B. 1, Kim M. 1, Cho S. 1 Anam Hospital, Korea University Radiology Seoul -Korea, South 1

As we know, bilateral hydronephrosis should be treated to prevent progressive renal deterioration. Various conditions causing bilateral hydronephrosis (ex. bilateral ureteral stones, tumor invasions of bilateral ureters, etc.) require percutaneous nephrostomy (PCN). However, PCN is not the only way to resolve the bilateral hydronephrosis. Some conditions can be just managed by percutaneous suprapubic cystostomy (ex. bladder outlet obstruction including BPH, prostate cancer or urethral stricture), manual reduction (ex. cystocele) and indwelling Foley catheter (ex. neurogenic bladder). We classify bilateral hydronephrosis according to the level of obstruction with the appropriate procedures for resolving it. In this presentation, we discuss the benefits, loss and indication of percutaneous nephrostomy, review the diseases which can cause bilateral hydronephrosis with imaging appearances and illustrations, and discuss the clues allowing the decision to do or not to do PCN. This pictorial review reminds a practical concept for bilateral hydronephrosis according to its causes and provides appropriate treatment algorithm.

P5-03 - ENDOVACULAR EMBOLIZATION OF RENAL ARTERY PSEUDOANEURYSM FOLLOWING PERCUTANEOUS NEPHROLITHOTOMY Akmangit İ. 1, Dede D. 1, Sayın B. 1, Rona G. 1, Gürel F. 1 Ankara Numune Education and Research Hospital Radiology Ankara-Turkey 1

Objective: Renal artery pseuodoaneurysm is a rare but potentially life threatening condition that is may happen following percutaneous procedures. Selective renal embolization is currently considered as the most appropriate technique in the treatment for renovascular complications with success rate grater than %80 and low complication rate. We describe presentation and endovascular manangment of a case of intrarenal pseudoaneurysm of the right kidney following percutaneous nephrolithotomy(PCNL).

159 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Method: A 53-year-old man with multiple calculus in the right kidney was submitted to PCNL . Patient was disharged in postoperative day 3 and readmitted with gross hematuria a month later after the procedure. Patient underwent computed tomoghraphy angiography(CTA) and digital substraction angiography(DSA).

Result: CTA showed laceration and subcapsular hematoma in the lower pole of right kidney. And an inferior branch pseudoaneurysm was diagnosed at CTA. After a right femoral approach under floroscopic control superselective catheterization into the inferior pole segmental artery was achieved. İodophentilate oil was mixed with N-butyl-2-cyanoacrylate. The resulting mixture was injected continuously under floroscopic control to prevent reflux into the renal artery. After withdrawal of coaxial catheter control angiography did not show further opacification of the pseudoaneurysm.

Conclusion: The reported indicence of renal pseudoaneurysm following PCNL is 0,6 to 1%. Patient often present in delayed fashion. Pseudoaneurysm must be ocluded with a permenant agent at the fistulous point where the risk of hemorrhage is grater. Selective angiography and embolization together is the gold standart, both for diagnosis and treatment. In contrast to surgery, endovascular manangment

P5-04 - SPORADIC RENAL ANGIOMYOLIPOMA WITH CO-EXISTENT HAEMORRHAGIC ANEURYSM AND TREATMENT Hatti D. 1, Nural M. 2, Danaci M. 2, Belet U. 2 TSMU Radiology Tbilisi-Georgia 1 Ondokuz Mayıs University Radiology Samsun-Turkey 2

AML is known most commom benign mesenchymal tumor of kidney. We report a case of haemorrhagic aneurysm in a sporadic AML diagnosed by a method of MRI and angiography and treated by selective arterial embolisation.Tumor and aneurysm diameter have been used as predictors of rupture. Super selective renal artery embolisation(SRAE) is an effective and minimal invasive method for the control of renal haemorrage. Radiologists should aware with complications of AML such as intratumoral bleeding with subcapsular, perirenal or pararenal haematoma and rupture of aneurysm.

P5-05 - CHRONIC EXPANDING HEMATOMA A REAL CHALLENGE! Aydın M. 1, Gürel S. 1, Gürel K. 1, Coşgun Z. 2, Canan A. 1 Abant İzzet baysal üniversity Radiology bolu-Turkey 1 Silifke Devlet Hastanesi Radiology Silifke/MERSİN- Turkey 2

Objective:Our aim is to present a rare Chronic Expanding Hematoma case with illustrative CT, MRI and DSA findings.

Method:Patient underwent noncontrast CT of the abdomen, dynamic pelvic MRI, pelvic angiography and left internal iliac artery selective angiography. Consequently percutaneous placement of drainage catheter and pouch graphy were applied.

Results :This 67 years old male suffering from left gluteal and pelvic regional pain, micturition and defecation problems and muscle weakness of the left lower extremity referred to emergency. There was no significant laboratory and physical examination findings.A noncontrast abdominal CT was followed by a contrast enhanced dynamic MRI. A big mass lesion was located within minor pelvis, extending through the left gluteal muscles and compressing sigmoid colon. Mass displayed signals presenting different phases of hemorrhage and showed no contrast enhancement. And the radiologic diagnosis was pelvic hematoma. A pelvic arteriography and drainage of the hematoma was ordered. No active bleeding, aneurysm or pseudoaneurysm was found . A catheter was placed within the mass no drainage was present, the final diagnosis was a chronic expanding hematoma possibly originated from the lateral sacral branch of left internal iliac artery and this confirmed surgically.

Conclusıon:Most hematomas resolve rapidly without causing notable clinical problems.Those that continue to bleed may act as expanding lesions with acute and serious pressure symptoms if they occur in some strategic location.This entity may be misdiagnosed as a malignant tumor due to its large size and slow progressive enlargement.Various kinds of imaging modalities have been utilized for diagnosis.

www.esur2013.org 160 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P5-06 - ENDOVASCULAR TREATMENT OF CIRSOID TYPE OF SPONTANEOUS BILATERAL RENAL ARTERIOVENOUS FISTULA Acu B. 1, Fırat M. 2, Gökçe E. 3, Beyhan M. 3, Kurtuluş E. 1 Osmangazi University Medical Faculty Radiology Eskişehir-Turkey 1 Ankara Guven Hospital Department of Radiology Radiology Ankara-Turkey 2 Gaziosmanpaşa University Medical Faculty Radiology Tokat-Turkey 3

Objectıve: Renal arteriovenous fistula(AVF) is a well-known cause of hematuria.In most cases they are secondary to invasive procedures.Spontaneous AVF of the kidney are much rarer and less well known than the secondary forms.We aim to present endovascular treatment of cirsoid type of spontaneous renal AVF.

Method: A 42year-old woman was admitted with right flank pain and massive hematuria with clot retention. Abdominal CT and bilateral selective renal artery angiography were performed.

Results: On CT scan, a small soft tissue mass was depicted within the right renal pelvis.The lesion did not enhance after injection of contrast medium.Cystoscopy and upper tract cytology were both negative for a high-grade bladder tumor.Selective bilateral renal arteriography was carried out following the resolution of the hematuria,and demonstrated an area of tortuous,coiled vascular channels with early filling of renal vein.Therefore,bilateral peripelvic cirsoid type renal AVF was diagnosed and a transcatheter superselective embolization of the lesion with the use of coils was performed successfully during the same session.

Conclusion: Two types of spontaneous renal AVF of the kidney have been described: Cirsoid (or congenital) and idiopathic (or aneurysmal).Cirsoid fistulas are characterized by a tangle of tortuous vessels of small diameter,with multipl varix-like communications between the artery and the vein and arteriovenous shunting. Arteriography is the more sensitive diagnostic tool for renal AVF. Endovascular treatment of a renal AVFs is technically feasibl using coil embolization.The potential benefits of a percutaneous management strategy include avoidance of nephrectomy,reduced perioperative risk,decreased postoperative morbidity,decreased operative time and hospital stay, and decreased renal ischemia.

161 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 6 – Functional Imaging

P6-01 - DIFFUSION-WEIGHTED IMAGING SPECTRUM OF SMALL RENAL MASSES Danacı M. 1, Çamlıdağ İ. 1, Nural M. 1 Ondokuz Mayıs University Radiology Samsun-Turkey 1

Background and objective: The great majority of renal masses are found incidentally due to the increasing abdominal cross-sectional imaging. Despite all the advances in imaging, the incidence of benign histopathology for malignancy-suspected renal masses still remains high as the conventional imaging features of malignant and some benign lesions may overlap and characterization is harder especially in small lesions. Recently, diffusion-weighted magnetic resonance imaging (DW-MRI) has proved to be helpful in characterizing renal masses. We aimed to illustrate the spectrum of small renal masses(<2.5 cm) showing diffusion restriction on diffusion-weighted imaging (DWI) through 15 adult cases. Methods: We retrospectively reviewed conventional MR images and qualitatively evaluated DWI in 15 adult cases with renal mass lesions smaller than 2.5 cm.

Results: Majority of the masses were malignant (8 histopathologically-proven renal cell carcinomas, 2 metastases).2 of the masses proved to be pyogenic abcesses by imaging-guided aspiration and disappearing after treatment. One of them was a component of hepatosplenorenal candidiazis disappeared after treatment in an immunocompromised patient, one was a histopathologically-proven tuberculosis granuloma and one was a non-fat containing angiomyolipoma.

Conclusion: Although a renal diffusion-restricting mass lesion is highly suggestive of malignancy, it should be kept in mind that inflammatory lesions and sometimes a benign mass lesion like an angiomyolipoma can also restrict diffusion. DWI should be used as complementary and/or in conjunction with the conventional imaging findings and clinical history.

P6-02 - REPRODUCTIBILITY OF APPARENT DIFFUSION COEFFICIENTS MEASUREMENTS IN DIFFUSION-WEIGHTED MRI OF THE KIDNEYS WITH DIFFERENT B VALUES Bilgili Y. 1, Inal M. 1, Daphan B. 1 Kirikkale Universitesi Medicine Faculty Radiology Department Kirikkale-Turkey 1

Purpose:To test the reproducibility of apparent diffusion coefficients (ADC) measurements of the kidney with different b values.

Materials and methods:Eleven healthy volunteers were imaged twice with use of the same DWI protocol. Each DWI was performed with b-factors of 0, 100 and 500 s/mm2. The ADCs were organized according to session (1 or 2) and repetition (twice with two different b value per session). The ADC data were analyzed with repeated-measures analysis of variance to demonstrate the influence of session and different b values. The coefficient of variation was calculated for each subject and bvalue then analyzed by using repeated- measures analysis of variance.

Results:There were significant differences in mean ADCs with different b values (P < .05). There were no significant differences in ADCs between imaging sessions 1 or 2 for both b values (P > .05). The CV values range between 10.4% and 14.7%. There were no significant differences in CV values between the two b values (P > .05).

Conclusion:Using the same technical parameters, patients and the same observer, CV values range between 7.3% and 14.7%. And we recommend to be careful in examination and comparison of the measured ADC values, below these limits, without knowledge technical parameters that has been used, otherwise differences that are merely because of changes in the measurement technique could be interpreted as differences because of progression of disease or therapy.

www.esur2013.org 162 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 7 – Minimally Invasive Therapies

P7-01 - THE EVALUATION OF EFFECTIVENESS OF DIFFERENT SOLUTIONS TO DECREASE THE CARBONIZATION EFFECT DURING RENAL RADIOFREQUENCY ABLATION APLICATIONS;EX VIVO Cengız A. 1, Tuncel S. 2, Temızoz O. 3, Caglı B. 2, Sıvrı F. 2, Genchellac H. 2, Unlu E. 2 Agri State Hospital Radiology Agrı-Turkey 1 Trakya University Radiology Edirne-Turkey 2 Selcuk University Radiology Konya-Turkey 3

Objective:Recent RFA technology enables the ablation of zones within 3.5 to 4.5 cm diameter. During radiofrequency ablation, with each radiofrequency heating, sudden temperature increase in tissue-electrode interface cause tissue desiccation and carbonization. It is aimed to extend the limitation of RFA with the effect of liquid collections at different concentrations and properties on Ex vivo.

Method:There were 36 of excised fresh bovine kidney, which weigh about 500 gr each for the experiment. It was compared the effectiveness of 6 groups of liquid solutions in different concentration and with different characteristics (Group 1, 0.9% NaCl, Group 2,3.6% NaCl, Group 3, 0.9% KCl, Group 4, 3.6% KCl, Group 5, 5% dextrose, Group 6 Ringer’s lactate). StarBurst Talon ablation probe were used in the process.Probe was inserted into kidney parenchyma and unfurled 3 cm than it was heated to about 105 0C for 5 min. Liquid solutions were infused with a speed of 1 ml/min. The kidney blocks were imaged three plans T2 weighted sequence at 1.5 T MR scanner. The dimensions of ablation zone and the effect of carbonization were evaluated with MR imaging and histopathologically.

Results:No carbonization was observed in neither microscopic nor macroscopic level in ablation zones. There were no dimensional differences observed in ablation zones between different liquid solution groups. The volume of the zones measured by MR was less than macroscopic measurement.

Conclusion:It was concluded that liquid solutions at different concentration and properties might be beneficial for clinical RFA treatment of tumours since it showed same coagulation necrosis.

P7-02 - BODY AND BONE APPLICATIONS OF MAGNETIC RESONANCE GUIDED FOCUSED ULTRASOUND TREATMENT Oh Y. 1, Park M. 1, Yoon S. 2 Severance Hospital Radiology Seoul-Korea, South 1 CHA Bundang Medical Center Radiology Seongnam- Korea, South 2

Learning objectives: Magnetic resonance imaging-guided focused Ultrasound (MRgFUS) treatment is a recently developed noninvasive treatment method that integrates FUS and MRI system. MRI can provide the imaging information and real-time thermometry for target definition, treatment planning, and closed-loop feedback of energy deposition. With the successful treatment results of uterine leiomyomas, it is expanding application fields.

We propose to attend this objectives:

1. To understand basic knowledge of Magnetic Resonance Guided Focused Ultrasound Treatment. 2. To describe the clinical advantages of Magnetic Resonance Guided Focused Ultrasound Treatment over the conventional treatments 3. To demonstrate the body and bone applications of Magnetic Resonance Guided Focused Ultrasound treatment, especially regarding to the uterine leiomyoma, prostate cancer, metastatic bone disease.

163 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 8 – Prostate

P8-01 - STRONTIUM-89 FOR PROSTATE CANCER WITH BONE METASTASES THE POTENTIAL OF CANCER CONTROL AND IMPROVEMENT OF OVER-ALL SURVIVAL Kuroda I. 1, Aoyagi T. 1, Shimodaira K. 1 Ibaraki Medical Center, Tokyo Medical University Urology Ami-Japan 1

Objective:Strontium-89 (Sr89) has been thought to have a tumoricidal effect with minimal adverse events. However, there have not been many reports on it. We examined the tumoricidal and pain-relief effects of Sr89 on prostate cancer with bone metastasis and also survivals.

Methods: A retrospective study was performed involving 31 prostate cancer patients with bone metastasis treated with Sr89. Using PSA as an evaluation criterion of cancer control, patients were divided into PSA responder and non-responder groups, and the survival rates were compared. In addition, using the total amount of pain killers as an evaluation criterion of pain relief, patients were divided into pain responder and non-responder groups, and the survival rates were compared. As secondary investigation items, age, PSA, pain site, EOD, CRPC, past medical history of treatment with docetaxel, Gleason Score, Hb, Plt, ICTP, and BAP were investigated.

Results: Longer survival was expected for the PSA responder than the PSA non-responder group, and, as predictors of this, whether the spine was the pain site or not and the presence or absence of CRPC were useful. Plt, ICTP, and BAP were suggested to be useful indicators; however, no significant difference was noted. Furthermore, the survival time was significantly longer in the pain responder than in the pain non- responder group, and whether the pain site was present in the spine was considered to be a predictor, but no significant difference was noted in any of the items assumed to be biomarkers.

Conclusions: Sr89 has a potency to control PSA and prolong the survival.

P8-02 - HIGH-DOSE-RATE INTERSTITIAL BRACHYTHERAPY AS MONOTHERAPY FOR CLINICALLY LOCALIZED PROSTATE CANCER EARLY EXPERIENCE Veleva V. 1, Hadjidekov G. 2, Nedev K. 3, Petkova E. 3, Parvanova V. 3, Balabanova A. 3, Dimitriu E. 3 University Hospital “Lozenetz” Department of Urology Sofia-Bulgaria 1 University Hospital “Lozenetz” Department of Radiology Sofia-Bulgaria 2 National Oncological Hospital Department of Radiation Oncology Sofia-Bulgaria 3

Introduction:To report the clinical outcome of high-dose-rate (HDR) interstitial (IRT) brachytherapy (BRT) as sole treatment (monotherapy) for clinically localized prostate cancer.

Methods And Materials:First 27 patients with clinically localized prostate cancer were treated with HDR interstitial brachytherapy as sole treatment (monotherapy) in our department between October 2010 and April 2013, as part of scientific project “Prostate cancer – diagnosis, prognosis, radiotherapy and follow-up”- №РНФ01/0135 sponsored by Scientific research found, Ministry of Education and Science. 27 patients received 31.5 Gy, using 3 single-fraction implants of 10.5 Gy (3 weeks apart) and intraoperative TRUS real-time treatment planning with 192-Ir sourse via Microselectron HD afterloader and Oncentra Prostate Planing System. Mean age was 65,6 y. (range, 51-76 y), mean initial PSA was 5.3 ng/ml (3,7 - 12), mean Gleason score 5 (2- 6), T stage range T1-2a, mean number of transperineal needles was 14 (10 - 17). Average prostate volume was 27,8 cm3.

Results: Median follow-up was 10 months (range 1-27). Mean value PSA at 6 months was 0.016 (0.01 -0.28) Average postoperative hospitalisation duration was 1,5 days ( range, 1-5) and no rehospitalisation was needed. All patients had macroscopic haematuria which required lavage via 3-way urethral catheter for 24 hours. Significant acute toxicities included clot retention (1 patients), grade 2 genitourinary toxicity was 1%; 2 patients experienced grade 3 toxicity. No acute grade 3 gastrointestinal toxicity was observed.

Conclusions:Our cohort experienced toxicity similar to previously published HDR monotherapy series with very promising early efficacy results.

www.esur2013.org 164 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-03 - COMPARISON OF GRANULOMATOUS PROSTATITIS WITH PROSTATE CANCER USING TRANSRECTAL ULTRASONOGRAPHY (TRUS) Moon S. 1, Lim J. 1 Kyung Hee University Hospital Radiology Seoul-Korea, South 1

Objective: to evaluate the imaging findings of granulomatous prostatitis (GP), and to differentiate GP from prostate cancer (PC) by using TRUS.

Methods: 11 patients with GP and 44 patients with PC were included this study. TRUS images were reviewed by two radiologists blinded to the diagnosis made by TRUS-guided biopsy. Serum PSA level and prostate volume were assessed. In image analysis, the presence of focal lesion, lesion shape, margin, echogenicity, and heterogeneity, and the presence of hypervascularity on CDUS were assessed. Shape was classified into nodular, nodular-infiltrative, and infiltrative shape. Margin was classified into well-defined, clear margin > 90%; moderate, clear margin > 50%; fair, clear margin < 50%; and poor, indistinct margin. Serum PSA levels, prostate volumes, lesion shape, margin, and echogenicity were statistically analyzed by using Mann-Whitney U test. Lesion heterogeneity and the presence of hypervascularity on CDUS were analyzed by using x2 test.

Results: Mean serum PSA level and prostate volume of GP were significantly smaller than those of PC (4.5ng/mL vs. 89.4ng/mL; 25.8cc vs. 36.7cc, p<0.05). Nodular and nodular infiltrative shapes were significantly more common in GP than in PC for both reviewers (100% vs. 18.2% for reviewer 1, and 90.9% vs. 31.5% for reviewer 2, p<0.05). Lesion margin was significantly clearer in GP than in PC (72.7% vs. 9.1% for reviewer 1, p<0.001; 63.7% vs. 14.3% for reviewer 2, p=0.056). Lesion echogenicity was significantly lower in GP for both reviewers (p<0.05).

Conclusions: GP frequently showed nodular shape, clearer margin, and hypoechogenicity as compared with PC in TRUS.

P8-04 - PERIPHERAL ZONE PROSTATIC LESIONS ROLE OF DIFFUSION WEIGHTED MAGNETIC RESONANCE IMAGING IN DIFFERENTIATING BENIGN FROM MALIGNANT LESIONS Afifi-hafez a. 1 faculty of medicine radiology alexandria-Egypt 1

Objectives: Peripheral zone prostate is the mainstay for 70% of cancer whereas the remaining 30% could be of benign nature. Recent studies showed that DW T2 WI MRI and DWI might be an effective adjunct tool in the localization and diagnosis of peripheral gland prostate cancer with its ability to differentiate the cancer prostate from other benign neoplastic and inflammatory conditions. In the current study we evaluated the role of the MRI and diffusion weighted MRI in this differentiation

Methods: Thirty male patients having peripheral gland pathology , confirmed with transrectal US followed with conventional and DWI MRI studies for evaluation of the prostate were done. For Histopathological evaluation, targeted trans-rectal US-guided biopsies were taken.

Results: According to MRI signals and presentations, in our study, 30 patients had peripheral zone lesions (24 isolated peripheral zone and 6 mixed peripheral and central zones).Twenty five patients proved malignant , two with granulomatous prostatitis and two were adenomatous hyperplasia and last one with focal inflammation. Diagnostic accuracy of 93% for diagnosing malignant from benign lesions was detected with only two cases with ,one with adenocarcinoma and one patient with adenomatous hyperplasia.

Conclusion: T2 signals and DWI , ADC applications added a lot in the field of diagnosis and differentiation of peripheral prostatic lesions as well as in the staging of proved cases with prostatic

165 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-05 - THE USE OF TRANSRECTAL ULTRASOUND AND MRI IN THE DIAGNOSIS OF PROSTATE EVASIVE ANTERIOR TUMOUR SYNDROME. Wadhwani S. 1, Barrett T. 1, Margolis M. 1, Ghai S. 1, Sreeharsha B. 1 Princess Margaret Hospital University Health Network Toronto-Canada 1

Objective: 1. To objectively assess the yield of transrectal ultrasound in PEATS. 2. To assess the effect of prior MRI examination on the yield of TRUS in PEATS. 3. To identify the confounding factors limiting diagnostic accuracy of TRUS in PEATS.

Method:Prostate Evasive Anterior Tumour Syndrome (PEATS) should be suspected in cases of raised PSA and negative initial biopsy. Retrospective review of 38 MR suspected, biopsy proven cases of PEATS, with transrectal ultrasound (TRUS) and MRI performed within 6 months of eachother, by 2 experienced Radiologists. Primary review of TRUS images was performed, followed by interval re-review after MRI evaluation after at least 1 month. Assessment of suspected lesion size, position, vascularity and echogenicity was assessed along with demographic and background gland characteristics (size, degree of background benign prostatic hypertrophy, calcification). Statistical analysis using Wilcoxson Signed Ranks test and McNemar tests for comparative data.

Results:Diagnostic yield of TRUS alone is low (25% and 50% for respective readers) with high interobserver variability (kappa coefficient 0.056). After MRI, assessment of TRUS yields slightly improved accuracy (47% and 58% respectively) but remains poor. Interobserver variability is improved (kappa coefficient 0.450) with no significant difference in positive cases between readers (p<0.344). Lesion size (AP or TS), vascularity and echogenicity are independent factors in lesion detection. Background BPH correlates negatively with TRUS lesion detection (p<0.05).

Conclusion:

1. The detection of PEATS is variable and poor using TRUS alone. 2. Prior MRI analysis improves TRUS lesion detection and reduces interobserver variability. 3. In cases of suspected PEATS, MRI is indicated after initial negative biopsy.

P8-06 - THE VALUE OF ELASTOGRAPHY IN EVALUATING FOCAL LESION SEEN ON TRANSRECTAL PROSTATE ULTRASOUND Lee H. 1, Moon M. 1, Hwang S. 2 Seoul National University Radiology Seongnam-Korea, South 1 Seoul National University Bundang Hospital Radiology Seongnam-Korea, South 2

Purpose: To evaluate the added value of elastography in evaluating focal lesion seen on TRUS and to suggest reference elasticity ratio for predicting prostate cancer

Patients and methods:From June 2012 to Februray 2013, 47 patients, who showed focal lesion on TRUS, were included this study. The diagnostic criteria for focal lesion include 1) increased vascularity on color Doppler image 2) peripheral location of the lesion 3) irregular margin 4) nodular low echoic lesion. If all the criteria were positive, the patients were classified as group 1. The other patients were classified as group 2. With gold standard of pathologic findings, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated based on TRUS findings. ROC was obtained for determining cut-off value of the elasticity ratio differentiating prostate cancer from other tissues. With both elasticity ratio value and TRUS findings, the sensitivity, specificity, PPV and NPV were also calculated.

Results: Based on TRUS findings, the sensitivity, specificity, PPV, and NPV were 66.7%, 69.2%, 63.6%, 72.0%, respectively. ROC curve analysis revealed that the cut-off elasticity ratio value discriminating prostate cancer was 2.4 with area under curve (AUC) of 0.69. Based on both elasticity ratio and TRUS findings, the sensitivity, specificity, PPV, and NPV were 57.1%, 100%, 100%, 74.3%, respectively.

Conclusion: The elasticity ratio of 2.4 or more suggests prostate cancer on elastography. The peripherally located focal nodular lesion with increased vascularity, irregular margin and elasticity ratio of 2.4 or more showed very high probability of prostate cancer.

www.esur2013.org 166 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-07 - VALUE OF T1 T2-WEIGHTED MR IMAGING REGISTRATION TO REDUCE POST BIOPSY HEMORRHAGE EFFECT IN LOCALIZATION OF PROSTATE CANCER Lee H. 1, Yu J. 2, Moon M. 1 Seoul National University Radiology Seongnam-Korea, South 1 Seoul National University Bundang Hospital Radiology Seongnam-Korea, South 2

Purpose: To evaluate feasibility of T1/T2-weighted MR imaging registration(T1/T2 registration) for reducing biopsy hemorrhage effect in prostate cancer.

Materials and Methods: Twenty one patients (mean age, 68 years; range, 60-75 years) who were available whole-mount histopathologic sections analysis for use as a reference standard. The zonal anatomy was divided into 16 sections. T2- weight imaging and T1/T2 registration imaging were scored for the likelihood of tumor by four radiologists (2 faculty and 2 trainees) and finally compared with whole-mount histology results. The area under the receiver operating characteristics curve was used to assess diagnostic accuracy.

Results: For faculty (reader 1 and 2), there were no significant difference of the AUC values between T1/T2 registration and T2-weighted imaging in tumor detection. The AUCs for readers 1 and 2 were 0.60 and 0.62, respectively for T2-weighted imaging, and 0.60 and 0.62, respectively for T1/T2 registration imaging. For trainees (reader 3 and 4), the AUC values were significantly higher (p=0.03 and 0.04, respectively) for T1/T2 registration imaging (0.60 and 0.62, respectively) than for T2-weighted imaging (0.54 and 0.56, respectively). Specificity was also significantly higher (p=0.02 and <0.001) with T1/T2 registration imaging than with T2- weighted imaging for both of trainees. However, interobserver agreement for the detection of prostate cancer was fair with 0.21-0.40 kappa value on both T2-wighted imaging and T1/T2 registration imaging.

Conclusion: T1/T2 registration imaging increases diagnostic performance in comparison with T2-weighted imaging for the detection and localization of prostate cancer for trainees, however, it has limited value for faculty.

P8-08 - DOES THE MAXIMUM CANCER CORE LENGTH ON 5MM TEMPLATE TRANSPERINEAL PROSTATE MAPPING BIOPSIES CORRELATE TO THE HIGHEST GLEASON SCORE EL-Shater Bosaily a. 1, Freeman A. 2, Jameson C. 2, Brown l. 3, Kaplan R. 3, Emberton M. 1, Ahmed H. 4 UCL/UCLH Department of surgery and interventional science London-United Kingdom 1 UCLH Department of pathology London-United Kingdom 2 MRC Medical research coucil London-United Kingdom 3 UCL/UCLLH Department of surgery and interventional science London-United Kingdom 4

Introduction: Prostate cancer is a heterogeneous disease. Individual lesions in the same gland are different in volume and grade , also areas within the same lesion are heterogeneous. Risk-assessment and clinical- significance depend on both Gleason score(GS) and cancer volume represented by maximum cancer core length(MCCL). We aimed to determine whether the MCCL of individual lesions harbored the highest GS. In other words, does the grade hotspot of a tumour coincide with the volume hotspot or does the tumour hotspot as some have argued, not reside in the area of maximum cancer-burden?

Methods: PROMIS is validating cohort study representing level 1evidence. It will assess the role of multi- parametric MRI in men with an elevated PSA prior to biopsy. All men undergo mp-MRI followed by5mm Template Prostate Mapping biopsies as well as TRUS biopsy under GA. Each core is individually oriented in space and the GS and MCCL assigned this allows the unique opportunity to explore grade and volume heterogeneity within individual lesions by creating a 3Dhistological prostate representation .

Each lesion was assessed separately. In those lesions with GS7 or greater,MCCL and maximum GS were recorded.

Results:47lesions have been identified in total. 23lesions had GS>/=3+4; 16lesions were GS3+4, 6 lesions were GS4+3 and 1lesions were GS4+4.Of all 23lesions with GS>/=3+4, 16(69.5%) showed concordance between the highest GS and MCCL within that lesion. When there was discordance the highest grade was in another core the mean difference between the core with MCCL and the core harbouring the highest GS was 3(range1-8).

Conclusion: The early outputs from PROMIS demonstrate that the core with the highest burden of cancer from a 5mm sampled lesion usually harbors the highest grade. This may have implications on the targeting strategies based on novel imaging.

167 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-09 - THE PROSTATE MRI IMAGING STUDY (PROMIS) EL-Shater Bosaily A. 1, Ahmed H. 2, Hindley R. 3, Louise Brown, L. 4, Parker C. 5, Kaplan R. 6, Emberton M. 1 UCL/UCLH Department of surgery and interventional science London-United Kingdom 1 UCL/UCLH Department of pathology London-United Kingdom 2 Hampshire Hospitals NHS Foundation Trust Department of Urology Hampshire-United Kingdom 3 MRC Medical research coucil London-United Kingdom 4 Royal mars den NHS trust Medical oncology London-United Kingdom 5 MRC Medical oncology london-United Kingdom 6

Background: TRUS biopsies are currently prone to random and systematic errors when detecting prostate cancer. Multi-parametric MRI (MP-MRI) may improve the diagnostic pathway.

Methods:PROMIS is a STARD compliant multicentre, diagnostic study that meets level 1 evidence in diagnostic test evaluation that investigates whether MP-MRI can discriminate between men with or without clinically significant cancer who are felt to be at risk with no prior biopsy. Up to 714 men will have MP-MRI (index), 10-12 core TRUS biopsy (standard) and 5mm TPM sampling (reference). Results of each test will be blinded until all results are available. Clinically significant cancer is defined as dominant Gleason pattern ≥4 and/or cancer core length of ≥6mm (UCL definition 1).

Results:PROMIS will measure sensitivity and specificity of MP-MRI and TRUS relative to TPM. The MP-MRI results will be used to determine the proportion of men who could safely avoid biopsy without compromising detection of clinically significant cancers in other men. Cost-effectiveness of MP-MRI prior to biopsy will also be evaluated. PROMIS will asses inter-observer variability among reporting radiologists and the learning curve required for to report MP-MRI. PROMIS will also generate a validated tissue, histology and imaging biobank for translational research.

Conclusions:PROMIS will determine whether introduction of MP-MRI prior to the current standard TRUS biopsy improves accurate diagnosis. If successful, MP-MRI could substantially reduce the number of men referred for biopsy and/or improve the detection of clinically significant cancer.

P8-10 - SHEAR WAVE ELASTOGRAPHY FOR DETECTION OF PROSTATE CANCER A PRELIMINARY STUDY Kim S. 1, Woo S. 1, Cho J. 1, Kim S. 1 Seoul National University Hospital Radiology Seoul-Korea, South 1

The purpose of this study was to assess the diagnostic value of Shear Wave Elastography (SWE) for detection of prostate cancer (Pca).

Patients suspected of Pca underwent a protocol-based, pre-biopsy SWE followed by biopsy of the prostate gland. Two ROIs (R1, R2) were placed in each sector along the estimated path for biopsy to calculate the Young modulus (kPa). Quantitative evaluation of SWE parameters (Smean [mean of R1, R2], Smax [greater value between R1, R2], Rmean [Smean of core / lowest Smean of patient], and Rmax [Smax of core/ lowest Smean of patient]) were correlated with histopathology on a per-core basis. The cutoff value derived from results of 12-core biopsy was applied to the targeted biopsy. In patients diagnosed with Pca, SWE parameters were correlated with the Gleason score (indolent [< 8] vs aggressive [≥ 8]).

87 Patients (1042 cores) participated in the study. Pca showed significantly higher stiffness for all SWE parameters (P < 0.006 for all). Data analyzed per core yielded a sensitivity/specificity of 40%/81%,21%/98%, 60%/67%, and 63%/64% using Smean (> 43.9 kpa), Smax (> 120.8 kpa), Rmean (> 3), and Rmax (> 3.6), respectively. Not only did all SWE parameters showed a significant linear trend with Gleason score: r = 0.316-0.397 (P = .001-.007) but were significantly different between indolent and aggressive Pca (P = 0.002- 0.006).

SWE parameters were significantly different between Pca and benign prostate tissue and showed significant correlation with Gleason score. The diagnostic accuracy for detection of Pca did not reach levels to recommend SWE-targeted biopsy.

www.esur2013.org 168 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-11 - ADDITIONAL MIDLINE CORE BIOPSY IN ULTRASOUND GUIDED 12-CORE PROSTATE BIOPSY DIAGNOSTIC ROLE TO DETECT MIDLINE ONLY PROSTATE CANCER Kim S. 1, Hwang I. 1, Cho J. 1, Kim S. 1 Seoul National University Hospital Radiology Seoul-Korea, South 1

To assess the clinical, pathologic features and diagnostic role of midline core biopsy in addition to 12-core biopsy protocol in prostate cancer (PCa).

Between October 2012 and May 2013, a total of 282 patients who had 12-core trans-rectal ultrasound (TRUS) guided prostate biopsy scheme with additional midline core were included. Patients were divided into three groups by their pathologic results: PCa with involvement of midline core, PCa without midline core and no tumor. Clinical characteristics and pathological features in biopsy specimens were analyzed.

There were 104 patients (36.9%) with PCa and 178 (63.1%) patients without PCa. Among PCa patients, there were 21 patients (20.2%) diagnosed PCa in midline core. However, there was no patient only diagnosed PCa in midline core. Multiple or multifocal disease was more frequently reported in midline positive PCa group in terms of more number of positive cores (9.7 vs. 3.3, P < .001). In addition, higher Gleason score (8.2 vs. 6.7, P < .001) and higher total tumor length/core length ratio (61.3% vs 35.5%, P < .001) in midline positive PCa group compared to those of midline negative PCa group, respectively. In terms of clinical features, prostate volume, PSA level and PSA density (PSA level/prostate volume) was not significantly different between midline positive and negative PCa group.

Midline positive PCa patients are more likely multiple or multifocal PCa with high tumor burden. However additional midline core biopsy may not be helpful to detect occult midline prostate cancer.

P8-12 - THE PROSTATE TREATED FOR PROSTATIC CARCINOMA MR PATTERNS Cardone G. 1, Papa M. 1, Messina A. 2, Lazzeri M. 3, Losa A. 3, Panizza P. 2, Guazzoni G. 3, Balconi G. 1 San Raffaele Turro Hospital Radiology Milan-Italy 1 Istituto Nazionale Tumori Radiology Milan-Italy 2 San Raffaele Turro Hospital Urology Milan-Italy 3

Objective:The most important surgical and ablative treatments for prostate cancer are: a) radical prostatectomy, b) radiotherapy, c) brachytherapy, d) cryoablation and e) HIFU ablation. Aim of this study is (A) To illustrate the most frequent MR imaging appearance of the prostate treated for prostate cancer, after surgical and ablative treatments. (B) To review the most common postoperative complications and the most frequent recurrence patterns after prostate surgical and ablative treatments.

Method:249 patients treated with radical prostatectomy, radiotherapy, brachytherapy, cryoablation and HIFU ablation performed MR follow-up between July 2008 and February 2013. All MR examinations were performed with a 1.5T MR system, using a endorectal coil. All the patients underwent MR conventional multiplanar TSE T2w sequences, followed from dynamic axial contrast enhanced ce GRE T1w sequence. In some pts we also performed MR spectroscopic acquisitions.

Results:We evaluated the following MR imaging patterns of the prostate treated for prostatic carcinoma: a) Morphology; b) Signal intensity; c) Contrast enhancement patterns on dynamic studies. We evaluated also the most common postoperative complications and MR most frequent recurrence patterns.

Conclusion:MR is an effective imaging technique in the follow-up of treated prostate. The most effective examination techniques were multiplanar TSE T2w and dynamic GRE T1w sequences. A useful additional technique is MR spectroscopy. The most important parameter in the evaluation of recurrences was the presence of nodular patterns of enhancement on dynamic MR study in the treated areas. The most frequent post operative complications were haematomas, fluid collections and collecting system fistulas.

169 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-13 - PROSTATIC CARCINOMA TREATED WITH FOCAL BRACHYTHERAPY MAGNETIC RESONANCE IMAGING PATTERNS Cardone G. 1, Messina A. 2, Papa M. 1, Losa A. 3, Lazzeri M. 3, Panizza P. 2, Guazzoni G. 3, Balconi G. 1 San Raffaele Turro Hospital Radiology Milan-Italy 1 Istituto Nazionale Tumori Radiology Milan-Italy 2 San Raffaele Turro Hospital Urology Milan-Italy 3

Objective:To report the spectrum of MR findings of prostate gland treated with Focal Brachytherapy. To illustrate MR imaging effectiveness in the early evaluation of post-implant dosimetry in patients treated with Focal Brachytherapy.

Method: 9 patients with localized prostatic carcinoma underwent Focal Brachytherapy. The planning of the treatment was based on byoptic and preoperative MR imaging evaluation. Seeds were placed percutaneously with perineal approach, using endorectal sonography guidance. MR imaging follow-up was performed at 30 days and 3 and 12 months after therapy.

Results:On MR images performed 30 days after the treatment we evaluated the morphology of the gland, the seeds position and the post implant dosimetry. On MR images performed 3 and 12 months after the treatment we evaluated the morphology and the patterns of vascularization and functionality of the gland. MR imaging follow-up showed reduction in size of treated areas, with diffuse reduction in signal intensity, contrast enhancement and cholin levels, due to parenchimal fibrosis and atrophy. PSA level decreased in all the patients at 12 months after the treatment (mean PSA level 2,2 ng/mL). MR imaging follow-up revealed no evidence of recurrence in all the patients.

Conclusion:In our preliminary experience Focal Brachytherapy resulted a safe, well tolerated and minimally invasive therapy in selected patients with prostatic carcinoma. MR can be an effective imaging technique in the follow-up, in particular in the evaluation of post-implant dosimetry. MR imaging can also play a role in the evaluation of patients with clinical or laboratory suspect of recurrence.

P8-14 - MID-TERM MRI FOLLOW-UP AFTER FOCAL CRYOTHERAPY FOR CLINICALLY LOCALIZED LOW RISK PROSTATE CANCER Cardone G. 1, Messina A. 2, Papa M. 1, Losa A. 3, Lazzeri M. 3, Panizza P. 2, Guazzoni G. 3, Balconi G. 1 San Raffaele Turro Hospital Radiology Milan-Italy 1 Istituto Nazionale Tumori Radiology Milan-Italy 2 San Raffaele Turro Hospital Urology Milan-Italy 3

Objective:We report the mid-term (two years) MR imaging follow-up in patients who underwent Focal Cryotherapy for clinically localized low-risk Prostate Cancer.

Method: 11 patients with unifocal, low-grade clinically localized Prostate Cancer underwent Focal Cryotherapy. Patients were followed-up clinically, biochemically and by MR imaging 24 hours after surgery, and subsequently at 3, 12 and 24 months.

Results: In patients treated with Focal Cryotherapy, cryolesions tipically appear to be hyperintense with a hypointense peripheral rim in the early controls and hypointense in the following examinations on T2w images, due to the coagulative necrosis induced by cryotherapy. The treated areas showed a progressive decrease in size during the follow-up, due to fibrotic evolution of cryolesions, and no significant vascularization on ce-MR images, due to vasocostriction and thrombosis induced by cryotherapy. The most significant MR patterns were the decrease in size with the passing of time and the complete ischemia of the treated areas. 10 patients had a stable PSA level at 24 months after the treatment. One patient showed a neoplastic lesion in the contralateral side of the gland 12 months after treatment.

Conclusion: Our medium-term experience suggests that Focal Cryotherapy is a safe, well tolerated and minimally invasive therapy for localized Prostate Cancer in selected cases, and MR can be an effective imaging technique in the follow-up, in particular in the early evaluation of the effectiveness of the treatment (immediate feedback about size and geometry of the cryoinsult). The evaluation and MR correlation of patients with clinical or biochemical suspect of recurrence require further studies.

www.esur2013.org 170 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-15 - THE IMAGING FEATURES OF PROSTATE EVASIVE ANTERIOR TUMOUR SYNDROME A CASE SERIES. Wadhwani S. 1, Barrett T. 1, Margolis M. 1, Ghai S. 1, Sreeharsha B. 1 Princess Margaret Hospital University Health Network Toronto-Canada 1

Objective:Tissue diagnosis in prostate cancer is required for staging and grading, and to define further management. Standardised non-targeted transrectal ultrasound (TRUS) guided biopsy is commonly implemented in cases of suspicion, although these are frequently negative. In such cases PEATS should be considered. Repeated negative biopsies involve increased patient discomfort and morbidity. Furthermore, there is increasing popularity of focal tumour therapy, including ablation techniques. Therefore, knowledge and awareness of the specific imaging features in PEATS are of increasing importance. Diagnostic accuracy of TRUS is limited and MRI is the best available option. We report our experience of the imaging features in 6 patients with biopsy proven PEATS.

Method:We reviewed the imaging features of 38 cases of biopsy proven PEATS, performed at our institution. We analysed common imaging features with respect to multiparametric MRI and transrectal ultrasound. We selected 6 cases that demonstrate the relevant specific imaging features, for presentation.

Results:We describe the range of features encountered in standard TRUS and multiparametric MR examination including contrast enhancement/doppler flow and diffusion restriction. We display the specific features of anterior tumours, including MR contrast enhancement and doppler flow on TRUS. Finally, we illustrate the confounding features that contribute to difficult identification.

Conclusion:Increased awareness and better understanding of the features of anterior prostate tumors is essential to avoid repeated negative biopsies. MRI should be performed for all suspected cases of PEATS before further TRUS and biopsy.

P8-16 - MUCINOUS ADENOCARCINOMA OF PROSTATE MAGNETIC RESONANCE AND DIFFUSION- WEIGHTED IMAGING FINDINGS Erbay G. 1, Pekoz B. 1, Onal C. 2, Koc Z. 1, Karadeli E. 1 Baskent University Radiology Ankara-Turkey 1 Baskent University Radiation Oncology Ankara-Turkey 2

Objective: To present magnetic resonance imaging (MRI) findings of mucinous adenocarcinoma of prostate in a patient.

Method: MRI and diffusion weighted imaging (DWI) were performed in a patient with mucinous adenocarcinoma of prostate. The diagnosis confirmed by operative and pathological findings.

Results: A large prostate tumour appeared as high signal intensity lesion on T2 weighted images. It was hypointense on T1 weighted images because of its fluid content. We observe restriction on DWI due to hemorrhage of transurethral biopsy. Accurate restricted diffusion wasn’t identified in the tumour. The lesion enhanced peripherally on dynamic images. Although nonmucinous tumours have low T2 signal intensity, mucinous adenocarcinoma of prostate is observed usually hyperintense on T2 weighted images. It can be difficult to demonstrate small mucinous adenocarcinoma in peripheral zone of prostate because of its isointensity.

Conclusion: Mucinous adenocarcinoma of prostate is an unusual neoplasm. Nonrestriction lesions on DWI and progressive peripherally enhancement on dynamic images should be bring to mind musinous adenocarsinoma of prostate.

171 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-17 - RADCOMMUNICATOR AN IPAD APPLICATION FOR PI-RADS REPORTING OF PROSTATE MULTIPARAMETRIC MRI Petralia G. 1, Summers P. 1, Alessi S. 1, Antiga L. 2, Colombi M. 2, Bellomi M. 1 IEO Radiology Milan-Italy 1 Orobix Srl Bergamo- 2

Objective: to present RADcommunicator, a freely-available iPad application that facilitates the use of PI- RADS classification in structured reporting of prostate multiparametric magnetic resonance imaging (mp- MRI) and the communication of derived clinical results.

Method: RADcommunicator was developed by the European Institute of Oncology – IEO (Milan, Italy) and Orobix Srl (Bergamo, Italy), and is available via AppStore. RADcommunicator includes a standardized prostate reporting scheme (three axial sections: base, midgland and apex - subdivided into a total of 27 regions, and a coronal section of the prostate) on which the radiologist manually draws lesions. Each lesion is assigned a number, and scores on a five-point scale for T2 weighted imaging, diffusion weighted imaging and dynamic contrast enhanced MRI tabulated. Each lesion is given an overall score (PI-RADS) to predict its chance of being a clinically significant cancer. The completed reporting scheme can be forwarded by email and saved (to the device and/or server).

Results: In our institution, RADcommunicator reports have been well accepted by other physicians, and forms a basis both for communication between clinical specialties and research. The urologists routinely uses them to guide robotic-assisted radical prostatectomy, target biopsy, and improve patient management (e.g. patients candidates for/enrolled in active surveillance programs). Our pathologist uses them when matching pathology images to mp-MRI for research purposes.

Conclusion: In our experience, RADcommunicator facilitated routine use of the PI-RADS scoring system and enhanced the communication of clinical results derived from prostate mp-MRI to all physicians involved in the care of prostate cancer patients.

P8-18 - MORPHOLOGICAL ASSESSMENT OF ANTERIOR LESIONS ON PROSTATE MULTI- PARAMETRIC (MP) MAGNETIC RESONANCE IMAGING (MRI). EL Shater Bosaily A. 1, Ahmed H. 1, Emberton M. 1, Punwani S. 2, Freeman A. 3, Krkham A. 4 UCL/UCLH Devision of surgery and interventional science London-United Kingdom 1 UCL/UCLH Department of radiology london-United Kingdom 2 UCLH Department of pathology london-United Kingdom 3 UCLH Department of radiology London-United Kingdom 4

Introduction/Objectives: Anterior tumours are a diagnostic challenge–often missed on biopsy, and potentially identifiable on MRI. However, there is an overlap in appearance with adenomas even on a MP- MRI and it is necessary to take into account both morphological and signal intensity characteristics. We aimed to observe features helpful in distinguishing adenoma from tumor.

Materials/Methods: 31consecutive patients at our hospital(2007 -2011)underwent a)MP- MRI(biopsy naïve, PSA raised)with a suspicious lesion in the transition(TZ)but not peripheral zone(PZ), and b)Targeted biopsy(Transrectal or transperineal).

Significant tumour was defined as a cancer core length of>3mm or any Gleason4 component from histology in the area of suspicion on MRI.

MRIs were performed on a 1.5Tmachine using a pelvic phased array coil andT2, dynamic contrast-enhanced and diffusion weighted(for ADC maps and a dedicated b=1400 )sequences. PZandTZs were separately scored between 1(tumor very unlikely)and5(tumour very likely). The volume, relationship to the anterior fibro-muscular stroma(AFMS), signal intensity on enhanced and diffusion-weighted sequences and signal homogeneity were assessed

Results: Multiple parameters were assessed and the following was observed: First, a lesion was highly unlikely to be malignant if it did not abut or lie within the AFMS or if it did not show a pseudocapsule. If these lesions were reclassified as negative, 63%and 44%(respectively) of false positives in the TZcould have been avoided. Second, tumours showed high signal intensity on the b=1400image compared to TZ Third, homogeneity on T2and contrast-enhanced sequences predicted tumour.

Conclusion: We have identified multiple useful MRI features for incorporation into large prospective diagnostic studies to determine their clinical utility.

www.esur2013.org 172 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P8-19 - MAGNETIC RESONANCE IMAGING OF PROSTATE CANCER WHAT RADIOLOGISTS NEED TO KNOW Boussalah M. 1, Taghy F. 1, Siwane A. 1, Lezar S. 1, Essodegui F. 1 Ibn Rochd Teaching Hospital Central Radiology Casablanca-Morocco 1

Objectives: Magnetic resonance (MR) imaging plays a pivotal role in assessment of prostate cancer. We review the currently available MR methodologies for the evaluation of prostate cancer in a practical and integrated clinical context, discuss and illustrate the recent advancements in the field. We also argue the advantages and limitations of current diagnostic MR imaging of the prostate. In addition, we develop an imaging algorithm for MR imaging protocol of the prostate cancer.

Methods: Experience of our department and pictorial review of literature.

Results: Prostate cancer is the most frequently diagnosed cancer in males. It’s can be divided into detection, localization, and staging; accurate assessment is a prerequisite for optimal clinical management and therapy selection. Traditional prostate MR imaging has been based on morphologic imaging with standard T1-weighted and T2-weighted sequences, which has limited accuracy. Recent advances include additional functional and physiologic MR imaging techniques (diffusionweighted imaging, MR spectroscopy, and perfusion imaging), which allow extension of the obtainable information beyond anatomic assessment, and provides the highest accuracy in diagnosis and staging of prostate cancer.

Conclusion: Owing to its exquisite soft-tissue contrast, MR imaging is well suited for assessment of the prostate. It’s a rapidly evolving field, and the application of many new techniques to the evaluation of prostate cancer will continue to improve the diagnostic accuracy of prostate cancer.

P8-20 - BEYOND RECIST CRITERIA: THE ROLE OF MR PERFUSION IN EVALUATING RESPONSE TO ANTI-ANGIOGENIC THERAPY IN PATIENTS WITH METASTATIC RENAL CANCER. Barchetti F. 1, Forte V. 1, Iacovelli R. 1, Catalano C. 1, Panebianco V. 1 Sapienza University of Rome Department of Radiology Rome-Italy 1

Purpose: To determine the role of MRI perfusion technique in the evaluation of response to anti-angiogenic therapy in patients with metastatic renal cell carcinoma (RCC) assessing the dimensional changes and quantifying the degree of vascularization.

Materials and Methods: 46 patients (108 lesions) with primitive and/or metastatic RCC were evaluated with MRI before and during anti-angiogenic therapy (at 0, 4, 8 weeks); we assessed the dimensional changes of the lesion according to RECIST guidelines and the degree of vascularization of the lesions through the evaluation of the perfusion volume (PV) assessed by means of a T1-weighted GRE sequence acquired after intravenous administration of contrast medium and an evaluation software (Functool 7.4). Results: After 4 weeks we observed a response to therapy (complete or partial: CR/PR) in 67.7% of lesions considering the size criteria and 77.6% according to PV; stable disease (SD) in 6.5% considering RECIST and 3% according to PV; progression of disease in 25.8% according to RECIST and in 19.4% considering PV. After 8 weeks we reached a CR/PR in 74% of the lesions taking into account RECIST and in 80% considering PV, SD in 6% according to RECIST and in 0% taking into account PV, PD in 20% of the lesion considering both methods of analysis (RECIST and PV).

Conclusions: Functional MRI is a valid method for the evaluation of the phenomena of neoangiogenesis in primary and/or metastatic RCC; assessing the PV rather than the study of dimensional changes allows to evaluate the effectiveness of early anti-angiogenic therapy in

173 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 9 – Trauma

P9-01 - A NEW THEORY ABOUT PATHOGENESIS OF PENILE FRACTURES REPORT OF A CASE Tutar O. 1, Ustabasıoglu F. 1, Samancı C. 1, Korkmazer B. 1, Esenkaya A. 1, Demırdag C. 2, Cıtgez S. 2, Mıhmanlı I. 1, Kantarcı F. 1 Istanbul University Cerrahpasa Medical Faculty Radiology Istanbul-Turkey 1 Istanbul University Cerrahpasa Medical Faculty Urology Istanbul-Turkey 2

Objective :The aim of this study was to present a case with penile fracture and propose a new theory about pathogenesis of penile fractures.

Method : A 58-year-old male with discoloration of his penis was admitted to the emergency department. The patient reported a history of falling on to the erect penis 1 hour ago. He was referred to the urologist for investigation and treatment. Physical examination revealed swollen, ecchymotic and deviated circumcised penis and there was tenderness on palpation. Then Doppler and B-mode ultrasonography were performed and patient underwent surgery afterwards.

Results :Sonography revealed 15 mm transverse and 6 mm longitudinal tear in tunica albuginea in the proximal third of left penile shaft. Adjacent to the defect, there was also hematoma in the neighboring extratunical region. In addition to the sonographic findings, we also observed a “perforating artery” at the location of the fascial defect which spans from dorsal penile artery across tunica albuginea towards the cavernous body. Diagnosis of penil fracture involving the proximal third of left penile shaft was made based on ultrasound findings. On surgery penis was degloved and intra-operative findings revealed 15 mm defect at proximal left penil shaft. Defect was repaired without any complications.

Conclusion: According to our knowledge in English nomenclature the association between penil fracture and fascial weakness at the location of perforating artery of tunica albuginea was not mentioned. We hypothesize that fascial weakness of tunica albuginea due to perforating artery may cause susceptibility to penile fractures.

P9-02 - INGESTED FISH BONE AN UNUSUAL FORM OF DUODENAL AND URETHRAL PERFORATION cakir o. 1, yencilek e. 1, meric k. 1, aydın s. 1, simsek m. 1 haydarpasa numune research and training hospital radiology istanbul -Turkey 1

Ingestion of gastrointestinal foreign bodies represents a challenging clinical scenario.We present a case of 40-year-old male patient which was admitted in the emergency room department complaining of clinically diagnosed renal colic.Non-contrast CT scan confirmed the presence of a radiopaque linear object extending from the duodenal second part to the urethral lumen.At this site there was leakage of urine from the ureter. The foreign body was removed using a biopsy forceps and identified as a fish bone.No purulent drainage or hemorrhage was observed from the site duodenal penetration.The patient had an uneventful recovery. The strategically located site of penetration in the visceral wall is responsible for the often extraordinary gastrointestinal tract injury patterns. Increased level of suspicion is of paramount importance for the timely diagnosis and treatment.

P9-03 - THE VALUE OF MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF PENILE FRACTURE Ödev K. 1, Şimşek C. 1, Keskin S. 1, Kılınç M. 2 Necmettin Erbakan University Dept of Radiology Konya-Turkey 1 Necmettin Erbakan University Dept of Urology Konya-Turkey 2

Objective: We studied the use of magnetic resonance imaging(MRI) in the diagnosis of penile fracture.

Method: Between 1997 and 2012, fourteen patients (age rage 25-48 years,mean age 23 years) with suspected penile fracture underwent MRI examinations. Nine patients were injured during sexual intercourse, whereas five patient were traumatized by non-physiological bendind of the penis during self manuplation. İnvestigations were performed with 1.5T MR unit. With the patient in the supine position, the penis was taped

www.esur2013.org 174 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY against the abdominal wall and surface coil was placed on the penis. All patients were studied with axial, coronal, sagittal precontrast and postcontrast T1A TSE(TR/TE:538/13 msn) and T2A TSE(5290/110 msn) sequences. All patient underwent surgical exploration. The follow-up ranged from 3 months to 72 months. Clinically all patients showed normal healing process without complications. In 11 patients a shortening and thickening of tunica albuginea(TA) was observed. Three patients have post traumatic erectil disfunction.

Results: In all patient corpus cavernosum(CC) fractures were clearly depicted on a discontinuity of the low signal intensity TA. These findings were most evident on T1WI and also depicted on T2W sequences. İmages obtained shortly after contrast medium administration showed considerable enhanced only rupture site. Subcutaneous extratunical haematoma in all patients were also recognizable on T2 WI. MRI findings were confirmed at surgery.

Conclusion: Magnetic resonance imaging is of great value for the diagnosis of penile fracture. Furthermore this method is well suited for visualising the post-operative healing process.

P9-04 - RADIOLOGICAL FINDINGS IN URETHERAL PERFORATION Keskin S. 1, Keskin Z. 2, Poyraz N. 1, Ödev K. 1 Necmettin Erbakan University, Meram School of Medicine, Radiology Konya-Turkey 1 Konya Training and Research Hospital Radiology Konya-Turkey 2

Objective: Uretheral perforation is a rare urinary anomaly. We present radiological findings in a patient with uretheral perforation.

Method: A 74-year-old man was admitted to the urology department with left flank pain. Intravenous pyelography (IVP) and enhanced abdominal computed tomography (CT) were performed.

Results: IVP showed double collecting system and partial uretheral duplication in right kidney, delayed pyelogram phase, the evanescence of psoas muscle shadow, pelvicalyceal ectasis, the dilatation of proximal urether in left kidney. Aditionaly, the contrast extravasation around proximal urether in delayed pyelogram phase (240.min) was determined. The contrast material passing to the left distal urether was not determined. In abdominal CT, ectasis of left calyceal systems, extravasation of contrast material around proximal urether, 72 mm length mass near the left psoas muscle, heterogen density in fatty area and ectasis in left proximal urether was determined.

Discussion: Uretheral perforation is a rare urinary anomaly that is finished complications as retroperitoneal urinoma, urosepsis, abscess, infection aand acute renal failure. CT and IVP can be used for diagnosis.

P9-05 - URINARY TRACT IMAGING IN TRAUMA Boussalah M. 1, Benmoussa R. 1, Touil N. 1, Kacimi O. 1, Chikhaoui N. 1 Ibn Rochd Teaching Hospital Emergency Radiology Casablanca-Morocco 1

Objectives: Illustrate radiological aspects in urinary tract trauma, and provide to radiologists a pictorial review of cases met in our department, with tips and skills in basic’s CT interpretation.

Methods: We describe prospective finding in 45 patients with pelvic injuries, undergoing radiological exploration based on Multidetector computed tomography examinations.

Results: This pictorial essay reviews the computed tomography appearances of urinary tract trauma met in our department. The trauma circumstances were basically a road traffic accident (n=25). Hematuria was found in all cases, renal lacerations (20 cases), peri renal hematomas (15), and injuries to the extra renal collecting system, such as disruption of the ureteropelvic junction were found in 3 cases. Vascular injuries included dissection in two cases and a rupture of the urinary bladder in a complicated pelvic fracture.

Conclusion: The use of cross-sectional imaging, us MDCT improves surgical planning in urinary tract trauma. Radiologists are able to describe specifically these injuries to assess the initial injury, plan management, and predict prognosis.

175 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 10 – Paediatrics

P10-01 - UNILATERAL RETROILIAC URETER SMIULTANEOUS VISUALIZATION OF URETER AND ILIAC ARTERY WITH BIPHASIC CONTRAST ENHANCED MR UROGRAPHY Ince S. 1, Saglam M. 1, Kocaoglu M. 1 Gulhane Military Medical Academy Department of Radiology Ankara-Turkey 1

Objective: Retroiliac ureter is a rare congenital anomaly which may cause of noncalculous low ureteral obstruction. In this poster we aimed to discuss MR urography findings of this entity with a biphasic IV contrast material injection to be able to visualize the ureters and iliac arteries concurrently.

Method:A 6-year-old boy with mental and motor retardation was referred to our department of radiology for the suspicion of right lower ureteral obstruction. We performed modified MR urography technique in which half a dose of iv contrast was injected 10 minutes before the scanning and after the excreation of contrast in to the ureter other half a dose was given.

Results:Both ureters and major abdominal vessels were illustrated at the same time. We found the retroiliac course of the right ureter and proximal ureterohydronephrosis. The course and the caliber of left ureter was normal.

Conclusion:Several vascular abnormalities such as crossing accessory renal arteries, lumbar veins, retrocaval ureters, and ovarian vein syndrome may responsible for ureteral obstruction. Retroiliac ureter is an infrequent congenital condition that causes ureteral obstruction. Biphasic contrast enhanced MR urography should be considered as a noninvasive diagnostic procedure to be simultaneously showing the anatomical relationship of the collecting system and adjacent vessels.

P10-02 - DUPLICATED ECTOPIC URETER WITH VAGINAL INSERTION MR UROGRAPPHIC FINDINGS IN A 14-YEAR-OLD GIRL Ödev K. 1, Şimşek C. 1, Yurtçu M. 2 Necmettin Erbakan University Meram School of Medicine Dept. of Radiology Konya-Turkey 1 Necmettin Erbakan University Meram School of Medicine Dept.of Pediatric Surgery Konya-Turkey 2

Objective: To present the case of 14-year-old girl with a history of recurrent purulant vaginal discharge, dysuria,enuresis nocturna and urinary infection for fourteen years.

Case report: A 14-year-old girl presented with a complaint of recurrent dysuria, enuresis nocturna and urinary infection. Intravenous urography(IVU) showed that the right kidney was displaced inferiorly and dilated collecting system of the upper moiety of the right kidney. Retrograde urethro-cystography did not demostrate vesicouretheral reflux. T1 weighted 3D contrast enhanced gradient echo(GRE) sequences(TR/ TE:15/3msn, flip angle:30o-40o, FOV:360-390mm, matrix:192x512, slice thickness:1-5mm, scan duration: 3min) and T2-weighted MR urography(HASTE sequences) were performed. Axial, coronal, sagittal MR images of the abdomen were obtained. Magnetic resonance urography(MR Uragraphy) revealed the pelvic duplication of the right side with significant dilatation of the upper moiety ureter associated with the vaginal insertion.The ureter passed distally beyond the bladder and drained into the right anterior wall of the vagina. According to the imaging findigs ureteroneocystostomy was performed. The postoperative period was uneventful and the patient is currently alive and well 3 years after surgery.

Conclusion: MR urography is a useful method in the overall detection of a poorly functioning urinary tract moiety to its associated distal ectopic orifice. Its usefulness in our case suggests it has the potential to be a primary diagnostic method for this anomaly when it is not detected by standart imaging techniques.

www.esur2013.org 176 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P10-03 - EPIDIDYMAL ABSCESS IMPROVED WITH MEDICAL TREATMENT IN A CASE OF BEHÇET’S DISEASE ULTRASOUND FINDINGS BEFORE AND AFTER TREATMENT Artas H. 1, Saglam M. 1, Ince S. 1, Yıldırım I. 2, Ebiloglu T. 2 Gulhane Military Medical Faculty Department of Radiology ANKARA-Turkey 1 Gulhane Military Medical Faculty Department of Urology Ankara-Turkey 2

Objective:Epididymal abscess is an uncommon complication of epididymitis and may develop after untreated severe epididymitis. Epididymal tail is the most commonly involved location in epididymal abscess. Here, we presented the ultrasonographic findings before and after treatment of epididymal abscess in a patient with Behçet’s disease.

Method:A 40-year-old man with previously diagnosed Behçet’s disease was presented with a complaint of right scrotal pain, swelling, and scrotal erythema.

Results:A right-sided 3-4 cm nonfluctuant, firm, tender, scrotal mass was palpable at scrotal examination. Scrotal sonography demonstrated an enlarged right epididym and hypoechoic lesion at 3 cm diameter within the tail of right epididym. Color Doppler examination revealed peripheral vascularity. The clinical and ultrasonographic findings provided the diagnosis of epididymal abscess. After diagnosis, an antibiotic therapy was started. After 2 weeks, control ultrasound examination revealed resolution to 2 cm in size of the lesion. After 50 days, at ultrasonography, lesion was completely lost and epidydym was seen at normal echogenity and size.

Conclusion:Scrotal ultrasound is a noninvasive imaging method used to determine the diagnosis and effectiveness of treatment.

P10-04 - HYDROMETROCOLPOS IN A NEWBORN WITH ACCOMPANYING PERITONEAL COLLECTIONS AND CALCIFICATIONS Karaman Y. 1, Ozgür A. 2, Uslu A. 2, Türker F. 2, Taskınlar H. 2, Nass Duce M. 2, Apaydın D. 2 Antalya Education and Research Hospital Radiology Antalya-Turkey 1 Mersin University Faculty of Medicine Radiology Mersin-Turkey 2

Genital obstructions present with primary amenorrhea and periodical pain in pubertal age, abdominopelvic mass in newborns and result in hydro/hematometrocolpos. Vaginal atresia/stenosis and imperforated hymen are the most common causes. Imaging is necessary for both supporting the diagnosis and defining the level of obstruction. If endometrial fluid extravasates into the peritoneal cavity, peritoneal collections or calcifications are seen as a result of chemical peritonitis. In this study, hydrometrocolpos with peritoneal pseudocysts and calcifications in a newborn is presented with imaging findings.

A newborn girl, in whom fetal ascites was detected and hydrops fetalis was suspected on prenatal ultrasonography (US), was evaluated with US and then computed tomography (CT) after birth.

Physical examination revealed a pelvic mass and also a nodular protrusion between the labia majus. On US, a sausage-like cystic lesion with internal echogenities and fluid-fluid levels was detected posterior to urinary bladder. Multifocal loculated peritoneal collections were also present. Uterus could not be demonstrated. On CT, a bilobed midline cystic mass, compressing the bladder and extending into the vagina, was seen. The proximal component was significantly larger than the distal one. Loculated peritoneal fluid collections with calcified walls and multifocal peritoneal calcifications were also detected. Hydrometrocolpos and peritoneal pseudocysts due to extravasation of uterine content from fallopian tubes were assumed. In operation, vaginal atresia was found.

A midline cyst in a newborn girl may suggest hydrometrocolpos. Although peritoneal calcification in a newborn is the most common manifestation of meconium peritonitis, hydrometrocolpos-induced-calcifications should also be included in the differential diagnosis.

177 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P10-05 - OVARIAN TORSION IN PEDIATRIC PATIENTS IMAGING FINDINGS Karaman Y. 1, Ozgür A. 2, Cabuk G. 2, Zirek S. 2, Taskınlar H. 3, Nass Duce M. 2, Apaydın D. 2 Antalya Education and Research Hospital Radiology Antalya-Turkey 1 Mersin University Faculty of Medicine Radiology Mersin-Turkey 2 Mersin University Faculty of Medicine Pediatrıc Surgery Mersin-Turkey 3

Ovarian torsion is defined as partial/complete rotation of the ovarian vascular pedicle, causing obstruction to vascular inflow or outflow. It is a rare cause of acute abdomen in children. There is usually an underlying ovarian lesion, such as a cyst or teratoma; but the ovary may also be lesion-free. The clinical and laboratory findings are non-specific, thus imaging has an essential role in early diagnosis and treatment to preserve the ovarian function. Ultrasonography (US) and color Doppler US are usually sufficient for an accurate decision; computed tomography (CT) and magnetic resonance imaging (MRI) are useful to rule out non-ovarian pathologies and to detect accompanying ovarian lesions/hemorrhage. In this study, the imaging findings of intraoperatively proven ovarian torsions will be discussed.

Six girls, 1 day – 13 years of age, were included in the study. The symptoms/clinical findings were acute abdominal pain or abdominal mass or abdominal mass with virilizing symptoms. The initial radiological examination was US for all patients; CT or MRI was also performed in patients with controversial findings.

US findings were large complicated cysts with internal echogenities and septations or hyperechoic ovaries with peripheral cysts. On color Doppler US, different vascularity patterns were detected. CT showed hypodense nodular lesions without significant contrast enhancement. MRI of the patient with virilizing symptoms showed hemorrhagic enlarged ovary.

Ovarian torsion is an important cause of gynecologic surgical emergencies. Since delay in diagnosis may result in ovarian necrosis, intraabdominal infection, sepsis and even death, prompt and accurate diagnosis, supported with imaging findings, is essential.

P10-06 - MAGNETIC RESONANCE IMAGING IN THE MANAGEMENT OF DISORDERS OF SEX DEVELOPMENT Carbone S. 1, Cacchiarelli E. 1, Riversi V. 1, Bulotta A. 2, Ricci V. 1, Molinaro F. 2, Messina M. 2, Volterrani L. 1 University Hospital of Siena Department of Radiology Siena-Italy 1 University Hospital of Siena Department of Pediatric Surgery Siena-Italy 2

Objective: To show the utility of Magnetic resonance imaging (MRI) in the pre-operative management of disorders of sex development (DSDs).

Method: We retrospectively evaluated a sample composed of consecutve patients affected by DSD who were treated for genital reconstruction by the Pediatric Surgery Department of our hospital. Inclusion criteria were ambiguous genitalia at birth or assessment of internal genitalia in the presence of abnormal genitalia with hormonal or chromosomal abnormalities. We compared the imaging techniques that were used to visualize the anatomical features of this patients with MRI to demonstrate its utility in the surgical planning. All imaging examination were available of our institutional Picture Archiving and Communication System (PACS).

Results: We included 17 patients (median age of 6.7 ± 0.4 y.o.). After hormonal and genetic investigation, our patients displayed : 4 DSD 46 XX (21-hydroxylase deficiency), 6 DSD 46 XY (5-alpha-reductase deficiency), 3 DSD 46 XY (gonadal dysgenesis), 1 DSD 45 X0/46 XY (mixed gonadal dysgenesis) and 3 DSD 46 XX (vaginal agenesis). MRI, ultrasonography and cystoscopy were performed in all patients, fluoroscopy in only two patients (visualization of the anatomy of the genito-ureteral system), retrograde urethrography in seven cases. Laparoscopy was performed in four patients, allowing to demonstrate the presence of Fallopian tubes and gonads that could not be visualized using other radiological techniques.

Conclusion: Comparison between data obtained from MRI and echotomography, genitogram, cystoscopy and urethrography, to gain a better understanding of which modality offers more precision for surgical planning.

www.esur2013.org 178 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 11 – Stone Disease

P11-01 - A HOOK-SHAPED STONE THE COEXISTENCE OF STONE AND INTRAUTERINE DEVICE IN THE BLADDER Oyar O. 1, Dinçel Ç. 2 İzmir Katip Çelebi University School of Medicine Radiology İzmir-Turkey 1 İzmir Katip Çelebi University School of Medicine Urology İzmir-Turkey 2

Objective:A foreign object in the bladder such as a contraceptive device which had migrated from neighboring organs or placed iatrogenically has occasionally been observed. However, the number of diagnoses pertaining to the coexistence of a contraceptive device and bladder stones is extremely rare.

Method:In this study, a case of a 35-year-old female patient, who has admitted to the hospital with the complaint of pelvic pain and hematuria, with a contraceptive device attached to the stone in her bladder, was reported. In order to diagnose pelvic plain (x-ray) film, transabdominal ultrasound and pelvic CT scans were taken.

Results:On the pelvic x-ray, an oval shaped opacity, about 2,5 cm in diameter, in conjunction with a hook-shaped contraceptive device at the lower part of the minor was detected. An echogenic focus and its acoustic shadow extended to the bladder base were sighted in the right lateral wall of the bladder via transabdominal ultrasonographic examination. An association of the stone and attached contraceptive device has been identified on direct plain film before it was verified on pelvic CT scans.

Conclusion:Intrauterine device was considered as misplaced into the bladder probably during insertion or secondary to incomplete perforation. The aforementioned stone attached to the intrauterine device was broken by implementing the endoscopic cystolithotripsy method, and then, both the stone pieces and the contraceptive device were successfully extracted from the bladder.

P11-02 - LOW-DOSE CT FOR RENAL COLIC WITH AUTOMATIC TUBE CURRENT MODULATION ASIR AND LOW KV IMPACT OF BODY MASS INDEX. Gervaise A. 1, Naulet P. 1, BEURET F. 1, Matthieu P. 1, Portron Y. 1, Lapierre-Combes M. 1 HIA LEGOUEST Imaging Department METZ CEDEX 3-France 1

Objective: To evaluate the impact of body mass index (BMI) on dose, diagnostic performance and image quality of a low dose CT for renal colic.

Materıals and Methods: This retrospective study included all patients who underwent a low dose CT for renal colic performed during year 2012 with automatic tube current modulation, Adaptive Statistical Iterative Reconstruction and low kV. Three readers independently reviewed all images and evaluated the presence of a renal colic, diagnostic confidence and image quality. These results and doses were compared between patients with different categories of BMI and between patients with BMI < 25 and ≥ 25 kg/m2.

Results: 39 patients had a BMI < 25 kg/m2 and 47 a BMI ≥ 25 kg/m2. There was no statistical difference between the accuracy rates for the diagnosis of renal colic averaged over all readers between both groups (95,7 % vs. 96,4 %, p = .83). Image quality and diagnostic confidence scores had a significant better rating for patients with BMI ≥ 25 kg/m2 compared to patient with BMI < 25 kg/m2 (respectively 3.7 vs. 3.4, p < .001 and 2.8 vs. 2.5, p < .001). Mean radiation dose for patients with BMI< 25 kg/m2 was 2.4 mGy in comparison with 3.7 mGy for patients with BMI ≥ 25 kg/m2.

Conclusion: Our low dose CT for renal colic has an excellent diagnostic performance for all patients with significantly better image quality and diagnostic confidence scores for patients with BMI ≥ 25 kg/m2 but also with greater doses.

179 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P11-03 - BEYOND THE UROGRAPHY SOLUTION OF THE URETERAL PATHOLOGIES ON CURVED PLANAR COMPUTED TOMOGRAPHY IMAGES Yildirim D. 1, Tutar O. 2 Centermed Advanced Imaging Center Department of Radiology istanbul-Turkey 1 Istanbul University, Cerrahpasa Medical Faculty Hospital Department of Radiology Istanbul- 2

Objective:Ureters are tubular structures that carry urine from the renal pelvis to the bladder. Ureteric pathologies are relatively common, including anatomical disorders (e.g., vascular pressure and UPJ stenosis), ureteral stricture, stones, and tumors. In this study, we aim to assess the value of generating curved planar reconstruction of the urinary tract in diagnosing ureteric pathologies.

Materials and Method: We used tomographic data from a group of patients who had previously undergone a urinary system examination using a multidetector computed tomography system at our clinic. The group included 4 male and 3 female patients and had a mean age of 32 years. We performed our evaluation by comparing the curved planar reconstruction against traditional methods including axial, coronal, sagittal, and 3D views in terms of diagnostic findings.

Results:We obtained new diagnostic findings from the curved planar reconstructions that were missing from the radiological reports based on the conventional views. Compression by elongated sigmoid colon or compression of the proximal ureter between hypertrophic inferomedial renal pole and psoas are only two of interesting cases. Also, in other cases, microcalcular obstruction thorough the vascular crossings or variative king formations had been reported causes for stenosis.

Conclusion:We think that using manually recontructed curved planar processing of thin-sections of obtained CT scans of the urinary tract can help radiologists make more accurate diagnosis and make physicians to adapt more easily to examinaation of the whole length of the ureters.

P11-04 - LOW-DOSE 64 MULTIDETECTOR COMPUTED TOMOGRAPHY UROGRAPHY DETECT KIDNEY AND URETERAL STONES AS WELL AS HIGH-DOSE Al-Amin M. 1, Hadjidekov G. 2, Diakov I. 3 University Hospital “Alexandrovska Department of diagnostic imaging Sofia-Bulgaria1 Hospital Lozenets Department of Radiology Sofia-Bulgaria 2 National Centre of Radiobiology and Radiation Protection Sofia- Bulgaria 3

Objective: As computed tomography urography is one of the most advanced imaging modalities and after 2000, it became one of the mainstream methods in uroradiology our goal is to present our initial experience for the diagnosis of of urinary tract calculi using low-dose protocols of research.

Method: There are different protocols based on the principles of ALARA. We have used two low-dose protocols with no special preparation for the patients: low-dose and ultra-low dose. We use three phases and late excretory one made on 20-25 min. after the introduction of contrast medium, using single – bolus technique. Reconstructions are made on Maximim intensity projection and on Volume rendering. Our study is based on two groups patients: one with the 100 kVp / 163 eff. mAs. and the second with 80 kVp / 114 eff. mAs.

Results: There are significant differences between the protocols up to 63 % reduction in effective dose which is estimation of radiation risk and up to 66% dose reduction in measurable quantities CTDI and DLP. Moreover the images obtained with the new low-dose protocols have maintained their quality and shows the same diagnostic results.

Conclusion: MDCT is the most sensitive and specific test for the diagnosis of urinary tract calculi. CTU is detailed examination of the urinary tract. Radiation dose is an important issue. The obtained image, as shown by our low-dose protocols is comparable in image quality to the standard low-dose protocol, even with a lower radiation dose.

www.esur2013.org 180 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P11-05 - THE CAUSE AND THE RESULT TOGETHER URINOMA WITH URINARY STONE INSIDE Karaman Y. 1, Ozgür A. 2, Katar D. 2, Kara E. 2, Yıldız A. 2, Apaydın D. 2 Antalya Education and Research Hospital Radiology Antalya-Turkey 1 Mersin University Faculty of Medicine Radiology Mersin-Turkey 2

Urinoma can be defined as urine collection due to extravasation from urinary tract. It most commonly results due to trauma or obstruction. Because of the inconsistent radiological appearances, it can be mistaken with various pathologies. Although ultrasonography (US) is the elementary method to demonstrate the urinoma, computed tomography (CT) is the study of choice, because it shows the location, dimensions and extent, defines the level of the leak, the accompanying congenital lesions, the presence and cause of probable obstruction. In this study, urinoma secondary to ruptured urolithiasis-induced urinary obstruction is presented.

One and a half-year-old girl was admitted with fever and acute renal insufficiency. She was evaluated with US and CT.

On US, both kidneys were enlarged with increased renal parenchymal echogenity. Bilateral mild hydronephrosis and a retroperitoneal collection in the posterolateral aspect of left kidney were detected. On contrast enhanced CT, there were parenchymal patchy hypodense areas concordant with pyelonephritis. A 10 mm urinary stone was present in the collection. Contrast leak into the collection was detected on pyelographic phase images. Urinoma was diagnosed. Ureteral catheter placement was unsuccessful; so percutaneous drainage was performed. On follow-up, leak stopped spontaneously and the urinoma resolved.

The prompt diagnosis of urinoma is important, because the treatment of uncomplicated cases is simple and easy. On the other hand, delayed diagnosis may lead to complications, such as abscess formation and electrolyte imbalance, preventing the appropriate therapy. Imaging plays a key role in both diagnosis and management of urinomas.

P11-06 - SHOULD ACCESS TO UNENHANCED MULTI-DETECTOR CT (CT KUB) IN SUSPECTED RENAL COLIC BE LIMITED Razack A. 1, Mossad M. 1, Chiu K. 1, Alaaraj H. 1 Hull and East Yorkshire NHS Trust Radiology Hull-United Kingdom 1

Objectives:In our tertiary centre, CTscan is available 24hours to Emergency physicians(EP). Urologists(UR) are located off-site and so majority of unenhanced CT KUB for suspected renal stones are requested by Emergency Physicians without Urologists opinion. We wished to assess if this working pattern reduces the positive yield for urolithiasis.

Methods:All CT KUB performed in our hospital between Jan2012 and May2013 was obtained from our prospectively maintained radiology database. Patient Demographics, referrer, time of referral, CT findings including alternate diagnosis and incidental findings were noted from the radiology reports.

Results:Total of 1163 patients were scanned with breakdown of referring specialities being 923 for EP, 103 for UR and 137 for others and the respective positive yield was 42.8% overall, EP was 44.0%, UR was 47.5% and Others 30.6% and alternate diagnosis was 13.4% overall, 11.5% EP, 17.4%UR and 23.4% for Others. The positive yield during working hours (9am -5pm) was 41.1% and out of hours was 44.6%. The Positive yield for women(26.8%)was significantly (p<0.05)lower than men(51.1%)

Conclusion:Positive yield of CT KUB in our institute is slightly low compared to other studies, but within acceptable range. No difference between normal working hours and out of hours but significantly poor yield in women. Our study also shows that there is a slightly higher yield for Urologists compared to Emergency Physicians and a low yield for other specialities. Therefore it may be possible to increase the positive yield and reduce unnecessary examinations, by limiting CT access to Emergency physicians and after Urologists review especially for women.

181 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P11-07 - SHERIFF BADGE IN BLADDER Celdirme E. 1, Gürel S. 1, Metin A. 2, Canan A. 1, Gur S. 1, Kocak M. 1, Aydın M. 1, Halıcıoğlu S. 1 Abant İzzet Baysal University Radiology Bolu-Turkey 1 Abant İzzet Baysal University Urology Bolu-Turkey 2

Objective: To present findings of few adult patients which has bladder stones; with kidney-ureter-bladder (KUB) graphy, ultrasonography (US) and computed tomography (CT).

Methods:Patients with hematuri is referred to our clinic for investigation of urinary tract stones. We performed KUB graphy, US and CT examinations.

Results:At KUB graphy, a sheriff badge-like calsification is seen at pelvis. US demostrated a mobile, calsified lesion in bladder and CT proved a star-like kalsified bladder stone.

Conclusion:Renal, ureteral, and bladder calculi are a common cause of hematuria. Most of the urinary tract stones are kidney stones. Rarely bladder stones can be seen during investigation of hematuria. If there is a predisposing factor, like spinal cord injury or bladder drainage catheter, insidence can increase. Bladder stones can be either formed in the upper urinary tract and been trapped in the bladder or formed in the bladder in the presence of outlet obstruction. Like renal calculi, bladder calculi usually consist of calcium oxalate and calcium phosphate. Calcull shape can be laminated, faceted, spiculated, or seedlike.

www.esur2013.org 182 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 12 – Infectious Diseases

P12-01 - THE MASS-LIKE RENAL TUBERCULOSIS A CASE REPORT Yılmaz Ö. 1, Dadalı Y. 2, Turan A. 3, Ünlü E. 1, Kalaç Ş. 4, Öztürk S. 4 School of Medicine, Suleyman Demirel University Department of Radiology Isparta-Turkey 1 Atatürk Chest Diseases and Chest Surgery Training and Research Hospital Department of Radiology Ankara-Turkey 2 Dışkapı Training and Research Hospital Department of Radiology Ankara-Turkey 3 Atatürk Chest Diseases and Chest Surgery Training and Research Hospital Department of chest disease Ankara-Turkey 4

Objective:Renal tuberculosis (TB) in endemic regions is a very common disease and a variety of renal involvement is described. Mass-like renal TB is a rare entity however it should be kept in mind in differential diagnosis of renal masses. We will present the Computed Tomography (CT) findings of a mass-like renal TB.

Method:25-year-old female patient who had type 2 diabetes mellitus and pulmonary TB with history of intermittent urinary tract infection since 3-4 years. In this process, she was treated with antibiotics and ultrasonography (US) was normal. When she refers to the hospital with recurrent complaints of pain, a suspicious malignant mass containing necrotic areas is seen by US and computed tomography (CT) is performed for differential diagnosis.

Results:At the pre and post-contrast images of computed tomography examination, approximately 4x3x2.5 cm sized mass lesion with cystic necrotic areas and heterogeneous enhancement was recorded on the upper pole of the left kidney (Figure 1¬¬¬¬¬-5). As a result of the ureterorenoscopic punch biopsy, the lesion was identified as necrotizing inflammatory tissue. In addition, mycobacterium tuberculosis was isolated from the urine culture.

Conclusion:Renal tuberculosis may occur with lower urinary tract symptoms suggestive of cystitis. When urinalysis shows pyuria and hematuria, bacteria cannot be isolated. Mostly, renal imaging procedures are applied by suspicion of renal TB. Appearance of renal calcification and necrotic cystic changes with abnormal renal contour should suggest renal TB at US and CT. The definitive diagnosis is performed by isolation of mycobacterium organism from urine or tissue biopsy.

P12-02 - INCIDENCE & OUTCOME OF AMEBIC LIVER ABCESS Mazher h. 1 al-shifa medical centre ultrasound FAISALABAD-Pakistan 1

Objective:Amebic liver abscess is a common infection in third world countries like ours due to poor sanitary arrangements.It presents with severe pain and high grade fever and if not diagnosed and treated promptly,may lead to complications and mortality.

Materials & Methods:All patients suspected of the diagnosis of liver abscess whether presenting to physicians or surgeon was referred for ultrasonography for the confirmation of the diagnosis.Basic biodata,coexisting medical or surgical diseases and relevant investigation were recorded,and patient was assessed for the need to aspirate the abscess.After initial treatment patients were reassessed for the need to aspirate the abscess on third day.Patients were followed clinically and ultrasonically on third,tenth and twentieth day.

Results:We had 188 cases in the study period of two years, from January, 2007 to 31st December 2008. There were 128(68 %)males and60(32%)females.Majority,156(76.6%),of the abscesses were singly,40(21%) had double and 4(2%)had three abscesses.166(83%)were situated in the right lobe,28(15%)in the left lobe and4(2%)had abscess in both lobes.16(9%)were aspirated at presentation due to their size or position. Only4(2%)were aspirated at first follow-up on third day due to non resolution of pain or fever or increase in size. All the patients who were not lost from follow up responded to standard treatment of metronidazole.

Discussion:Patients presents with right upper quadrant pain and fever. Clinical background and ultra sonogram give a reasonable suggestion about amoebic etiology.If initial aspiration is not indicated due to size larger than 5cm.or proximity to surface or non resolution of symptoms or lesion in left lobe,conservative treatment with oral or intravenous treatment is successful.

183 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P12-03 - EMPHYSEMATOUS PYELONEPHRITIS EMPHYSEMATOUS PYELITIS AND EMPHYSEMATOUS CYSTITIS CLINICAL AND IMAGING FINDINGS IN SIX PATIENTS Ödev K. 1, Şimşek C. 1, Keskin S. 1, Karalezli G. 2, Özbiner H. 1, Kalkan H. 1, Kılınç M. 2 Necmettin Erbakan University Meram School of Medicine Dept. of Radiology Konya-Turkey 1 Necmettin Erbakan University Meram School of Medicine Dept.of Urology Konya-Turkey 2

Objective: Our purpose is to descibe clinical and imaging finding in emphsematous infections in the upper and lower urinary tract.

Material and Methods: During period from 2003 to 2010, six patients who have localized gas producing bacterial urinary tract infections were examined in our department. They included one men and five women who ranged age from 45 to 60 years. Clinical features, radiological and biochemical findings and the type of treatment were reveiwed. Plain radiography, ultrasonography(US) and computed tomography(CT) were performed in all patients.

Results: All patients had insulin-dependent diabetes mellitus. Abdominal radiography revealed isolated retroperitoneal gas in one patient. At US, intrarenal gas was identified as echogenic foci with dirty shadows in 3 patients. Type I emphysematous pyelonephritis(EPN) (n=3) was defined as paranchymal destruction with either total absence of fluid content on CT or presence of a streaky or mottled gas pattern. Type 2 EPN (n=1) was defined either the presence of renal or perirenal fluid collection in associated with a bubly or loculated gas pattern or gas in the collecting system or renal or perirenal fluid containing abscess. Emphysematous pyelitis(EP) was defined in one patient. Emphysematous cystitis was defined in one patient and in this patient cystoscopy revealed submucosal bubbles.

Conclusion: Gas-producing infections of urinary tract is an uncommon serious life-threatening condition. Patients with a history of diabetes mellitus, presenting with an acute abdomen should be investigated for an underlying renal course. The CT is the best confirmatory test.

P12-04 - RADIOGRAPHIC APPEARANCE OF RENAL TUBERCULOSIS - A CASE REPORT Arıoz H. 1, Kabaalıoglu A. 1 Akdeniz University Hospital Radiology Antalya-Turkey 1

Objectives: Tuberculosis is a common disease, with 8 to 10 million new cases annually. Usually the lung is affected but the most common form of nonpulmonary tuberculosis is urogenital disease. We report a case of renal tuberculosis without known history of pulmonary tuberculosis.

Methods: A 42-year-old woman was admitted to our hospital with left flank and suprapubic pain. The initial diagnosis was cystitis.She was operated for a left kidney stone two months ago. The patient had several hematological and biochemical tests. Additionally an intravenous pyelogram (IVP), ultrasound(US) and computer tomography(CT) examinations were performed.

Results: Plain films showed calcifications, and pyelograms revealed irregular caliectasis and enlargement of left kidney. Renal US and abdominal CT depicted an inhomogeneous mass, simulating a renal malignancy and subcapsular collection. CT showed globular renal calcifications pathognomonic for renal tuberculosis. Histological examination of the specimens revealed an extended necrotic granulomatous tissue indicative of tuberculosis. Further identification of acid-resistant mycobacteria with Ziehl-Nielsen stain confirmed the diagnosis. Drug sensitivity test using molecular techniques demonstrated isoniazid and streptomycin resistance.

Conclusions: Genitourinary tuberculosis is the second most common form of the extra-pulmonary tbc. The signs and symptoms of renal tuberculosis mimic other infections of kidney and diagnosis isn’t always straightforward. Therefore, diagnostic awareness may prevent unnecessary morbidity. Radiologists should consider tuberculosis in the differential diagnosis of renal calcifications and masses of the urinary tract.

www.esur2013.org 184 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P12-05 - RADIOLOGIC ILLUSTRATION OF TUBERCULOSIS IN GENITOURINARY SYSTEM Moon S. 1, Lim J. 1 Kyung Hee University Hospital Radiology Seoul-Korea, South 1

Objective: To illustrate various imaging features of tuberculosis in genitourinary system.

Methods: The genitourinary tract is the most common site of extrapulmonary tuberculosis. Drug-resistant strains and HIV infection is the major cause of increasing incidence. We retrospectively reviewed the initial imaging features of tuberculosis involving genitourinary system in various image modalities (KUB, IVU, RGP, US, CT, and MRI) and disease progression on follow-up images.

Results: Genitourinary tuberculosis usually affected the kidney, ureter, bladder, testis, epididymis, and female genital tracts. Renal tuberculosis usually affects by hematogeneous route. It causes the papillitis and papillary necrosis which may develop cavity formation and destroy the renal parenchyma. Advanced disease leads to cortical scarring and atrophy. Calyx involvement results in infundibular and pelvic strictures. Final results are loss of function, and calcification of the entire kidney. Ureter involvement also results in ureter stricture, beaded appearances, and shortening. Tuberculous cystitis results in thickened and contracted bladder due to mural fibrosis. It can be caused by BCG instillation for transitional cell carcinoma treatment. Male genital tuberculosis is the subsequence of the upper genitourinary tract tuberculosis. Prostate, seminal vesicles, epididymis, and testis can be involved. US features of tuberculos epididymo-orchitis are helpful for the differentiation from non-tuberculous infection and tumor. Female genital tuberculosis may appear as salpingitis, and cause peritonitis or endometriosis. Multiple lymphadenopathy, ascites, and peritoneal thickening can be seen.

Conclusions: Thorough knowledge of imaging features of genitourinary tuberculosis is necessary for the accurate diagnosis, and appropriate and timely treatment of tuberculosis.

P12-06 - TUBERCULOSIS EPIDIDYMO-ORCHITIS AN UNUSUAL PRESENTATION OF TUBERCULOSIS Dadalı Y. 1, Turan A. 2, Dilli A. 2, Kalac S. 3, Calıkoglu Ü. 4, Bursalı I. 4 S.B. Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 1 Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 2 1S.B. Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi Chest Disease Ankara-Turkey 3 1S.B. Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 4

Objective: Tuberculosis (TBC) Epididymo-orchitis is a relatively rare disease of testicle and epididymis which is difficult to diagnose. We herein aimed to present this rare case.

Method: Thoracic and abdominal computed tomography (CT), testicle/scrotal ultrasonography (US), and Color Doppler ultrasonography (CDUS) were performed on the patient.

Results: In the physical examination, the left testicle/scrotum was swollen and tender. Urine ARB of the patient was positive, and tissue ARB from the epididymis was four positive. In the lung tomography (CT), there were nodular infiltration areas compliant with TBC in both lungs. In the whole abdomen CT, there were several lympodenopathy in the paraaortic plane the largest of which had size 22x15 mm, and there was heterogeneity in the mesenteric lipid plans. In the testicle/scrotal US, there was increase in size in the left testicle/scrotum (47x33 mm), and there were diffusely localized hypoechoic areas the largest of which measured 6 mm, and heterogeneity in parenchyma was observed. Left epididymis was thickened and in heterogeneous nodular appearance. In the left side, hydocele and debris showing leveling in places were observed. Scrotum wall was thickened. In the CDUS, increased vasculerity was present.

Conclusion: Genitourinary system is the most affected system in extrapulmonary TBC. Epididymis is the most common in TBC. In male cases with AC TBC where granulomatous lesions present in the testicles/ scrotal epididymitis, TBC should be considered in terms of extrapulmonary involvement. Diagnosis and differential diagnosis could be done by using radiological imaging modalities

185 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P12-07 - EMPHYSEMATOUS PYELONEPHRITIS IN TYPE II DIABETES Kalaycıoglu B. 1, Yılmaz H. 2 Seka Govermental Hospital Radiology Kocaeli-Turkey 1 Seka Govermental Hospital Urology Kocaeli-Turkey 2

Emphysematous pyelonephritis is a severe, acute necrotizing renal parenchymal and perirenal infection with formation of gas. Emphysematous pyelonephritis predominantly affects females with uncontrolled diabetes and can occur in insulin-dependent as well as non-insulin dependant patients. CT scan is the modality of choice for the staging of the parenchymal gas and to rule out obstruction.

We present a case of 58-year old male with uncontrolled diabetes mellitus who presented with dysuria and left flank pain in the emergency department. In abdominal CT imaging 64x52 mm cytic lesion containig air bubles was found on upper pole of left kidney. He was diagnosed as a case of emphysematous pyelonephritis.

Although no laboratory abnormalities were reported. Due to the life threatening nature of emphysematous pyelonephritis, the division of Infectious Diseases Department in our hospital sugggested parenteral antibiotic treatment. After introducing an ureteral J stent was in a retrograde fashion and patient were put on a third generation cephalosporin treatment.

P12-08 - CT & MRI IN DIAGNOSIS OF DIFFERENT URINARY TRACT INFECTION SPETRUM OF IMAGING FINDINGS Abou El-Ghar M. 1, Refaie H. 1, Abdelhamid A. 1, El-Diasty T. 1 Urology& Nephrology Center- Mansoura university Radiology Mansoura-Egypt 1

In this study we reviews the common different acute and chronic inflammatory conditions that affect the kidney with emphasis on the role of cross sectional imaging including computed tomography (CT) and Magnetic Resonance Imaging (MRI) in their diagnosis and management. CT and MRI become essential tools for diagnosis of renal infection and also allow detection of complications. To use CT or MRI in diagnosis in diagnosis of urinary tract infection depends upon the availability, experience and if there is contraindication of each. They may be used as complimentary studies in some patients. CT and MRI allow early diagnosis and management that decrease the incidences and degree of complications.

P12-09 - TUBERCULOUS SALPINGITIS AND PERITONITIS MIMICING OVARIAN CANCER IMAGING FINDINGS Dadalı Y. 1, Ünlü E. 2, Kalaç Ş. 3, Yılmaz Ö. 2 Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital Radiology Ankara-Turkey 1 Süleyman Demirel University Radiology Isparta-Turkey 2 Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital Chest Diseases Ankara-Turkey 3

Objective:Genital tuberculosis is an uncommon form of tuberculosis and clinical suspicion is important in diagnosis. In many cases, the initial diagnosis is usually an adnexal tumor or acute appendicitis. We will present the ultrasound (US) and computed tomography (CT) findings of a genital tuberculosis, which presents with bilateral cystic adnexal masses and peritonitis.

Methods:A 24-year-old female presented in our emergency department with abdominal pain, sensitivity and loss of weight. Initial diagnosis was acute abdomen and US (ultrasonography) and CT (computed tomography) examinations are performed. Bilateral multiloculated cystic adnexal masses and complicated ascites are observed. Serum CA125 is elevated and laparoscopy is performed because of suspicion of malignancy.

Results: At the US and CT examinations, bilateral multiseptated cystic adnexal masses with internal debris adherent to the uterus and intestine are seen. There was also exudative ascites. Exudative ascites, peritoneal implants ve bilateral distended tubes are detected at the laparoscopy. Histopathology showed caseified granulomatous inflammation. No acid-resistant bacilli (ARB) seen. Chest X-ray was normal. All of these findings are considered as tuberculous peritonitis and salpingitis. After anti-TB therapy, abdominal findings are completely resolved.

Conclusion:Genital tuberculosis is usually secondary to a primary focus elsewhere in the body, usually the lungs and genitourinary tract is the most common site of extrapulmonary tuberculosis. Females with genital tuberculosis may present with infertility, menstrual disorders, and pain. In our case, genital and peritoneal tuberculosis were seen together without pulmonary tuberculosis.

www.esur2013.org 186 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P12-10 - ENDOMETRIAL TUBERCULOSIS A CASE REPORT Ünlü E. 1, Dadalı Y. 2, Kalaç Ş. 3, Yılmaz Ö. 1 Süleyman Demirel University Radiology Isparta-Turkey 1 Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital Radiology Ankara-Turkey 2 Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital Chest Diseases Ankara-Turkey 3

Objective: Tuberculosis (TB) of the genitourinary tract is almost invariably secondary to disease elsewhere, usually in the lungs. We present a case of endometrial tuberculosis after many years of healed primary pulmonary tuberculosis.

Method:A 44-year-old female presented to our hospital with groin pain and vaginal bleeding. After clinical examination, Ultrasonography (US) is performed to evaluate pelvic organs and showed pathological endometrial findings. Endometrial biopsy is performed for definitive diagnosis.

Results: Ultrasound revealed the thickened and irregular endometrial cavity with cystic appearance. Histopathology showed findings of granulomatous endometritis. She had a history of treated pulmonary tuberculosis 35 years ago and chest X-ray showed sequelae of the disease. The case is considered as TB endometritis and received anti-TB therapy. Follow-up US and biopsy results were normal.

Conclusion:Patients with genital tuberculosis are usually young women during work up for infertility. The clinical presentation varies from patient to patient, symptoms like abdominal pain, dyspareunia and dysmenorrhoea are characteristics indicating a pelvic inflammatory disease. Because of the lack of special clinical and radiological features, diagnosis of genital tuberculosis may be difficult. Infertility, abnormal vaginal bleeding, abnormal sonographic findings and previous history of TB infection can bring to mind the genital tuberculosis.

P12-11 - COEXISTENCE OF COMPLETE URETERAL DUPLICATION AND PYELO-NEFRO-URETERO- CYSTITIS Kafadar C. 1, Arıbal S. 1, Sönmez G. 1, Kara K. 1, Saglam M. 1, Sıvrıoglu A. 2 Gata Haydarpasa Teaching Hospital Radiology İstanbul-Turkey 1 Aksaz Soldier Hospital Radiology Mugla- Turkey 2

A 21-year-old male patient was admitted to our hospital’s urology service suffering from acute left sided flank pain and dysuria. Physical examination showed costovertebral precision. Leukocytosis in his blood count and erythrocyte and leukocyte in his urine analysis were seen. Abdominal sonography showed severe dilatation of left kidney’s inferior caliceal system, increased caliceal wall thickness and thinning of renal parenchyma at this site (grade 4 hydronephrosis) leading to enlargement of kidney. Dilated inferior caliceal system showed continuity at it’s caudal side with a tubuler structure which has thickened wall and we suspected this might be a duplicated ureter. Contrast enhanced abdominopelvic computed tomography performed and showed complete ureteral duplication on left side. The ureter draining the upper pole were normal. Inferior caliceal system and the ureter’s wall was thick and enhanced. There was also stranding dansities in the periureteral fatty tissues and increase in bladder wall thickness compatible with cystitis. There was no renal or ureteral stone detected. We reported this case as pyelonephritis, ureteritis and cystitis coexisting complete ureteral duplication at left collecting system. Ureteral duplication is a congenital condition in which a single kidney is drained by two ureters and it is the most common anomaly of the urinary tract occuring in approximately 1% of the population . There is an increased frequency of ureteropelvic junction obstruction and vesicoureteral reflux in the lower pole ureter.

P12-12 - ACUTE PYELONEPHRITIS GOING THROUGHOUT ALL IMAGING ASPECTS Benmoussa R. 1, Boussalah M. 1, Touil N. 1, Kacimi O. 1, Chikhaoui N. 1, Halfiya A. 2 Ibn Rochd Teaching Hospital Emergency Radiology Casablanca-Morocco 1 Ibn Rochd Teaching Hospital Urology Casablanca-Morocco 2

Objectives: Acute pyelonephritis (APN) is known as an inflammation of the kidney and upper urinary tract, most commonly resulting from bacterial infection of the bladder. The purpose of this study is to provide through an iconographic review, a support showing different aspects of this disease as much as its complications.

187 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Method: We studied 88 patients with suspected diagnosis of APN, during a period of two years (from May 2011 to May 2013). All patients underwent first an ultrasound examination then Computed Tomography scanning.

Results: The diagnosis of APN was established half of cases. 78% were women. Infection was caused in 85,3% by Escherichia coli. Ultrasonography diagnosed APN in 65,9% of cases showing an increase in kidney size with hypoechoic areas in 53,6%, blurred margins in 24,4% and reduction of Doppler vascularity in 36,6% of cases. The abdominal CT showed in 34,1% of dismissed ultrasonographic diagnosis of APN, 4 case of perinephitic phlegmon and many perfusion troubles in the other cases.

Conclusion: APN is a severe stat responsible for a considerable mortality if not assessed in time. The ultrasonography is often insufficient to define APN. Nowadays, Doppler and abdominal CT are becoming more and more complementary.

P12-13 - KEYPOINTS IN CT GRADING OF EMPHYSEMATOUS PYELONEPHRITIS THROUGH AN ICONOGRAPHIC REVIEW Saoud S. 1, Benmoussa R. 1, Sakalli A. 1, Chikhaoui N. 1 Section of Emergency Radiology, Department of Radiology, University Hospital Ibnou Casablanca-Morocco 1

Objective: Emphysematous Pyelonephritis is a severe, necrotizing, life threatening infection of the renal parenchyma, characterized by the production of intra-parenchymal gas. The purpose of this study is to provide through an iconographic review, a support showing different aspects of this disease and to demonstrate the impact of CT grading in its management.

Methods: We present our experience of 8 cases of emphysematous pyelonephritis. Medical records were analyzed prospectively for demographic profile, presence of diabetes mellitus, mode of clinical presentation, and finds of microbiologic analysis. Emphysematous pyelonephritis was diagnosed based on demonstration of intra-renal gas by plain X-ray, ultrasound, and/or CT scan.

Results: Our 8 patients were all females, with pre-existing diabetes mellitus. Emphysematous pyelonephritis was right-sided in 6 cases and left-sided in 2 cases. Eschirichia Coli was found in 6 cases and Klebsiella in two. CT grading was class II in one, class IIIa in two, class IIIb in five.

Conclusion: Early CT scan based diagnosis can dramatically improve the prognosis of emphysematous pyelonephritis by grading and indicating the appropriate treatment to each situation. The radiologist should be able to classify these uncommon lesions to participate in therapeutic decisions.

www.esur2013.org 188 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 13 – Ultrasound Contrast

P13-01 - CYSTIC RENAL LESIONS INCIDENTALLY FOUND ON CT – WHAT`S NEXT CAN CONTRAST ENHANCED ULTRASOUND FURTHER SOLVE A PROBLEM Kekelidze M. 1, Wyler S. 2, Bachmann A. 2, Bongartz G. 1, Hohmann J. 1 University Hospital Basel Radiology Basel-Switzerland 1 University Hospital Basel Urology Basel-Switzerland 2

Purpose: to assess diagnostic performance of Contrast Enhanced Ultrasonography (CEUS) in characterizing complex renal cysts incidentally found at CT imaging and to determine whether CEUS is a sufficient single imaging modality for further lesion characterization.

Materials and Methods: We have analyzed 36 cystic renal lesions on CEUS incidentally found on CT. CT consisted of different scan series according to clinical indication. CEUS was performed after application of 1.5mL SonoVue within real-time acquisition of 3 min. Cystic lesions were classified according to Bosniak classification. Bosniak III/IV lesions diagnosed at CEUS were compared either to postoperative histological data or to more than 5 years follow-up examination.

Results: Seven lesions were classified identically (I:2, II:1, IIF:2; III:1, IV:1), 14 lesions were upgraded (I>II:1, I>III:1, II>IIF:1, II>III:1, II>IV:2, IIF>IV:5, III>IV:3) and 15 were downgraded with CEUS (IIF>no lesion:1, III>no lesion:2, II>I:2, IIF>I:3, IIF>II:5, III>II:1, IV>III:1) compared to CT preliminary diagnosis. All lesions classified as Bosniak III/IV with CEUS were further confirmed. CEUS showed sensitivity of 100%, Specificity - 90%, PPV - 85.7% and NPV - 100%. CEUS depicted 11 type IV lesions while CT suggested this diagnosis only in 2 cases.

Conclusion: CEUS can be used to reliably characterize cystic renal lesions incidentally found on CT when limited CT scan series does not allow precise lesion definition. This will result in significant cost savings (>50%), also avoiding additional radiation and nephrotoxicity related to contrast enhanced CT reassessment.

189 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 14 - Obstetrics Fetalimaging

P14-01 - ECTOPIC PREGNANCY IN A CESAREAN SECTION SCAR IMAGING FINDINGS AND SUCCESSFUL MANAGEMENT WITH LAPAROSCOPIC GUIDED VACUM ASPIRATION Koplay M. 1, Dogan N. 2, Sivri M. 1, Erdoğan H. 1, Çelik Ç. 3 Selcuk University, Medical Faculty Radiology Konya-Turkey 1 Selcuk University, Medical Faculty Gynecologic and Obstetric Konya-Turkey 2 Selcuk University, Medical Faculty Gynecology and Obstetrics Konya- 3

Purpose: Cesarean scar ectopic pregnancy (CSEP) is a fairly uncommon presentation of ectopic pregnancy. Diagnosis of CSEP is important because it may lead to complications such as uterine rupture, hemorrhage, hipovolemic shock, dissemine intravascular koagulasyon and maternal death. Primarily, benefited from transvaginal ultrasonography (TVUS) in diagnosis. We presented the TVUS imaging findings and the management method of CSEP.

Case: A 25 years old gravida 3 para 2 woman admit to our unit with vaginal bleeding and positive pregnancy test. Her hCG levels was 38067 mIU/mL. She had prior two cesarean section operations. On TVUS there was no gestational sac or fetal pole but near isthmus, close to previous cesarean section scar 36 x 42 mm diameter sac and a viable fetus with 5.3 mm crown to lump length was visualised. Colour Doppler US demonstrated a proliferative growth of peritrophoblastic vessels around gestational sac. She was diagnosed with CSEP. In the laparoscopy, vesicouterine peritoneum was incised to see the ectopic pregnancy in previous uterine cesaerean section scar but as the gestational sac was close to endometrial cavity, there was no visible swelling corresponding to gestational sac. In the real time TVUS, location of gestational sac was confirmed. After the vacum aspiration, on TVUS a significant decrase in size of the gestational sac and hCG levels was noted.

Conclusion: CSEP should be considered in patients with high hCG levels. In addition, important to know the TVUS findings for complications and differential diagnosis.

P14-02 - EXTRAHEPATIC BILIARY ATRESIA WITH CHOLEDOCHAL CYST PRENATAL MRI PREDICTED AND POST NATALLY CONFIRMED A CASE REPORT. Nori m. 1, Jampala v. 1, g r. 2 deccan college of medical sciences radiology hyderabad-India 1 deccan college of medical sciences pediatric surgery hyderabad-India 2

Objective : Extrahepatic biliary atresia is uncommon cause of neonatal Jaundice. Antenatal MR diagnosis of EHBA is not published till date. EHBA with cystic component is likely to be mistaken for choledochal cyst.

Method: Case report of antenatally predicted and confirmed postnatally by surgery and histopathology is being reported.Imaging features on Antenatal and post natal imaging studies Ultrasound,MRI,HEPATOBILIARY SCINTIGRAPHY are presented .

Results:By means of the imaging features,cystic biliary atresia is accurately predicted which was confirmed surgically and histopathologically. All imaging signs are analysed here with and the importance of prenatal diagnosis is emphasised.

Conclusion: Imaging helps in prediction of EHBA and helps early postnatal surgical referral aiding in improving results of Kasai’s portoenterostomy.

P14-03 - PLACENTA PREVIA PERCRETA WITH URINARY BLADDER INVASION CDUS AND MRI FINDINGS Cakir Pekoz B. 1, Koc Z. 1, Erbay G. 1 Baskent University Faculty of Medicine Radiology ADANA-Turkey 1

Purpose: To present color Doppler ultrasound (CDUS) and magnetic resonance imaging (MRI) findings of the placenta previa percreta with bladder invasion in two patients.

www.esur2013.org 190 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Materials and Method: CDUS examination and MRI were performed in two patients with placenta previa percreta. Diagnosis confirmed by operative and pathological findings.

Results: The first case is a 34 year old woman at 32 weeks of gestation. The second case is a 33 year old pregnant woman at 31 weeks of gestation. Both patients had previous cesarean delivery. Placenta previa totalis were identified on obstetric ultrasound examinations. CDUS showed abnormal placental-bladder wall interface hypervascularity. In both of the patients, diagnosis of placenta previa totalis and placenta percreta with bladder invasion confirmed by MRI with focal interruptions in the hypointense myometrial wall at the previous cesarean scar adjacent to the bladder and the abdominal wall. MRI findings include thick placenta with inhomogenous signal intensity and anterior abnormal uterine bulging.

Conclusion: Placenta percreta with invasion of the urinary bladder is a rare but potentially fatal condition if not recognized before delivery. Knowledge of CDUS and MRI findings are helpful for prenatal diagnosis to prevent perinatal complications.

P14-04 - PREGNANCY OUTCOMES OF MULTIPLE PREGNANCIES AFTER ASSISTED REPRODUCTIVE TECHNOLOGY. Niknejadi m. 1, Ahmadi f. 1, Niknejad f. 1, Rashidi z. 1, Haghighi h. 1 Department of Reproductive Imaging at Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran Department of Reproductive Imaging at Reproductive Biomedicine Research Center Tehran-Iran 1

Objectives: Comparison of adverse birth outcomes of multiple pregnancies and singleton pregnancies conceived by assisted reproductive technology (ART).

Method and materials: In a prospective study adverse pregnancy outcomes of multiple pregnancies were compared with singleton pregnancy after assisted reproductive technology. Prenatal outcomes of 703 patients who were conceived after Assisted Conception were investigated from 2009-2010 in Royan Institute. The antenatal monitoring (preeclampsia, PROM, IUFD, preterm Labor, low birth weight, abortion) was compared in two groups.

Result: multiple conceptions were 194 out 703. A total of 82/194 (42%) pregnant women diagnosed with at least one adverse pregnancy outcome and 112/194 pregnant women had a normal pregnancy. A total of 509/703 women conceived singleton pregnancies of which 454 were normal and 55cases diagnosed with adverse outcomes (10%). Compared with singleton pregnancies in vitro fertilization, multiples have an increased risk of adverse prenatal outcomes(Figure 1) particularly preterm birth and low birth weight(Figure 2). The result by chi-square test was statistically significant (P value =0).There were no significant differences in incidences of congenital malformations.

Conclusion:A significant risk of ART is multiple pregnancies. This study suggested that the ART multiple pregnancies have increased rates of adverse birth outcomes.

P14-05 - INCREASED NUCHAL TRANSLUCENCY AT 11–14 WEEKS OF GESTATION AS A MARKER FOR ADVERSE PREGNANCY OUTCOMES. niknejadi m. 1 1- Department of Reproductive Imaging at Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran 1- Department of Reproductive Imaging at Reproductive Biomedicine Research Center Tehran-Iran 1

Objective:To evaluate the association of increased fetal nuchal translucency( NT) and adverse pregnancy outcomes.

Method:The study was performed prospectively on 932 fetuses who were conceived after Assisted Conception independent of multiplicity between 11 and 13 weeks’ gestation by ultrasound. Maternal and fetal data (NT, caryotype, pregnancy outcome) and infant follow-up of 20 fetuses with first trimester NT thickness (NT>95th percentile for a given crown rump length (CRL)) were analyzed.

191 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Results: We observed no abnormal karyotypes . Normal infants were born and follow-up till one year in 9/20 fetuses with increased NT and normal karyotype . For the 3/20 fetuses with normal karyotypes, outcome was unfavorable and results in elective terminations of pregnancy (2 extremity anomalies, 1multiple anomalies),2/20 neonatal death with normal karyotype due to preterm delivery ,2/20 intrauterine fetal demise (IUFD) and 4/20 reduction due to multiplicity and their karyotypes were not available. In this study increased NT was associated with a higher incidence of adverse pregnancy outcomes (Likelihood Ratio=20.242, df=2, Sig<0.00).Based on further chi-square analysis no significant relationship existed between NT and method of conception (chi-square=5.1388,df=6,P-value=0.3443), nor was there a relationship between method of conception and presence of fetal anomalies (chi-square=4.332,df=6,P-value=0.388).

Conclusion: First-trimester increased NT thickness is associated with an increased risk of subsequent pregnancy complications and adverse pregnancy outcome. The need for prenatal screening is extra important in the case of assisted conception due to more concern over specific anomalies, multiplicity and poor

P14-06 - ROLE OF ULTRASOUND AND MAGNETIC RESONANCE IMAGING IN ASSESSMENT OF FETAL MALFORMATIONS Gürel S. 1, Canan A. 1, Halıcıoğlu S. 2, Çeldirme E. 1 Abant İzzet Baysal University Radiology Bolu-Turkey 1 Bolu İzzet Baysal State Hospital Radiology Bolu- Turkey 2

Objective: The aim of this paper is to illustrate the importance and diagnostic value of ultrasound (US) and magnetic resonance imaging (MRI) in scanning and detection of fetal anomalies.

Methods:Between January 2008 and June 2013, all pregnant patients in our clinics, who underwent both second- or third-trimester fetal US and MR imaging for a fetal indication were retrospectively evaluated.

Results:The fetuses had a variety of anomalies including central nervous system, thoracic, abdominal, and urogenital systems.

Conclusion:Congenital anomalies are present in approximately 2-4 % of newborns and are an important cause of fetal and neonatal mortality and morbidity. Birth and survival of an anomalous fetus depends on its earliest detection and complete delineation of the type and extent of the anomaly. US is the primary imaging modality for the evaluation of the fetus. It is safe for both fetus and mother, is relatively inexpensive, allows real-time imaging, and is readily available. Even if most ultrasound examinations are diagnostic, such limitations may require an alternative imaging method in more complex cases to confirm or complete ultrasound findings, to guide management of pregnancy and to plan intrauterine interventions, delivery, and postnatal care. With advent of newer techniques and availability of MRI, fetal MRI plays an important role as complementary method to ultrasound due to its multiplanar capability and tissue differentiation when additional information is needed to make treatment decisions during pregnancy.

P14-07 - ECHOGENIC FETAL KIDNEYS Ozkavukcu E. 1, Arslan F. 1, Haliloglu N. 1 Ankara University School of Medicine Radiology Ankara-Turkey 1

Objective and background: The echogenicity of the normal fetal kidney is similar to that of the liver and spleen. The differential diagnosis of echogenic fetal kidneys can sometimes be hard. Renal size and architecture, accompanying fetal abnormalities, and amniotic fluid volume assessment are the key factors in the differential diagnosis. Herein, we present different cases of echogenic fetal kidneys, along with the ultrasound and Doppler ultrasound images.

Case reports and imaging findings: Although the etiology has not been determined, increased renal echogenicity in normal sized fetal kidneys can be a physiologic variation. When the kidneys are small or normal in size, increased renal echogenicity with oligohydramnios is highly predictive for obstructive uropathy.

www.esur2013.org 192 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Bilaterally enlarged echogenic kidneys and loss of corticomedullary differentiation may be seen in autosomal dominant or recessive polycystic kidney diseases (ADPKD, ARPKD). Family history and ultrasound imaging of parents’ kidneys are important in the differential diagnosis of ADPKD. In ARPKD, there is usually oligohydramnios and there may be a previously affected sibling.

A detailed ultrasound imaging is important to detect accompanying fetal anomalies, such as trisomy 18 or 13. Overgrowth syndromes, Meckel-Gruber syndrome, and congenital infections are the other rare causes of echogenic fetal kidneys.

Conclusion:Differential diagnosis of the echogenic fetal kidneys is crucial for predicting the morbidity, or the mortality of the fetus, thus parental counseling.

P14-08 - ROLE OF FETAL MAGNETIC RESONANCE IMAGING IN DIAGNOSIS OF CENTRAL NERVOUS SYSTEM RELATED ANOMALIES Acu B. 1, Çoraklı M. 2, Gökçe E. 2, Kara T. 1, Beyhan M. 2, Kurtuluş E. 1 Osmangazi University Medical Faculty Radiology Eskişehir-Turkey 1 Gaziosmanpaşa University Medical Faculty Radiology Tokat-Turkey 2

Objective:The main imaging method used in evaluations of fetal central nervous system (CNS) and related anomalies is prenatal ultrasonography(US).Many of conducted studies showed that MRI provides additional contribution to US in evaluations of CNS pathologies and complex fetal anomalies.In our study,we aimed to reveal MRI’s role in diagnosis of CNS-related anomalies and to compare it with US.

Method:To 48 pregnant women aged between 16 and 44 who were sent to Ultrasonography Unit of Radiology Department of Gaziosmanpasa University between February of 2008 and March of 2012 for anomaly screening and who were diagnosed with CNS anomaly in obstetric US implementation;obstetric MRI examination was applied within 2 days after US examination.

Results:The anomaly finding which was found in the study at highest rate is meningomyelocele,it was found in 32 fetuses.Ventricular system anomalies were found in 30 fetuses,while posterior fossa anomalies were found in 29 fetuses.During our study, the number of fetuses where both of US and MR imaging methods gave some imaging results and the same radiological diagnosis was 18(37.5 %).In 9 cases,the localization of meningomyelocele sac which was determined by US changed with MRI.In 4 fetuses (8%) the meningomyelocele which could not be detected with US could be detected with MRI.Also in 4 cases (8%), the diagnosis made via US was changed when MRI examination was applied.

Conclusion: As a result; although US is a cheap method for using in US fetal screening, MRI examination after knowing US findings increases the reliability of diagnosis and also provides additional contributions.

P14-09 - FETAL BIOMETRY FOR TURKISH POPULATION Altın L. 1, Koç Altın E. 2, Karaltı M. 3, Parlak İ. 1, Toprak U. 1, Bostaoğlu S. 1 Ankara Numune Eğitim Ve Araştırma Hastanesi Radiology Ankara-Turkey 1 Ankara Meslek Hastanesi Radıology Ankara-Turkey 2 Marmaris Devlet Hastanesi Obstetrıcs And Gynecology Muğla-Turkey 3

Objectives: To obtain new reference charts and equations for fetal biometry in Turkey population.

Methods: Prospective observational data involving 8600 women with singleton pregnancies and confirmed gestational age obtained in four center. Between the 12-40th gestation, fetal biometric measurements; biparietal diameter, head circumference, abdominal circumference and femur length were recorded.

Results: New charts and reference equations are reported in our population for biparietal diameter, head circumference, abdominal circumference and femur length. The main difference in our fetal biometric measurements compared with those of the USA, UK and French populations was in FL.

Conclusion: We present new Turkey reference charts and equations for fetal biometry. They can be easily used in obstetric ultrasound studies for the Turkey population and may improve the diagnosis of a small for gestational age newborn.

193 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 15 – Combined ESGAR

P15-01 - RADIOLOGICAL APPROACH TO FAT CONTAINING ABDOMINAL MASSES Serter A. 1, Sharifov R. 1, Bilgin M. 1, Kocakoç E. 1 Bezmialem Vakif Univ Radiology Istanbul-Turkey 1

Objective:There are different fat containing lesions in abdominal solid organs, gastrointestinal tract, peritoneal and retroperitoneal area. Purpose of this presentation is to discuss Computed Tomography and Magnetic Resonance Imaging findings of fat containing abdominal masses and demonstrate features for differential diagnosis.

Material And Methods: Abdominal CT or MRI performed to the patients with different clinical history and diagnosis. We evaluated patients with fat containing abdominal masses (hepatocellular carcinoma, adenoma, angiomyolipoma, renal cell carcinoma, liposarcoma, omental necrosis, renal replacement lipomatosis, lipoma, teratoma, epiploic appendagitis, lymphangioma, etc.) with or without symptoms.

Results:CT and MRI are extremely guiding for diagnosis, appropriate treatment protocol and follow-up in the fat containing abdominal masses.

Conclusion:For fat containing abdominal masses; location of lesion, existence of macroscopic or microscopic fat, and presence of calcification are crucial for differential diagnosis. Density under – 20 HU on CT, hyperintense signal intensity on T1 and T2 images and signal loss on fat-suppressed images on MRI show presence of macroscopic fat. In and out of phase sequence of MRI determine microscopic fat with chemical shift artifact. Patient’s age and complaints, location of lesion and imaging findings often facilitate spesific diagnosis .

P15-02 - CT AND MR IMAGING OF NONGYNECOLOGIC PELVIC MASSES MIMICKING GYNECOLOGIC DISEASE Lee Y. 1 Kangbuk Samsung Hospital Radiology Seoul-Korea, South 1

Although the majority of pelvic masses in the female pelvis arise from the reproductive organs (eg, uterus, cervix, ovaries, fallopian tubes), diverse group of benign and malignant pelvic masses that arise from the gastrointestinal system, retroperitoneum or peritoneum may mimic those of gynecologic origin. Thus, the differential diagnosis for female pelvic masses with cross sectional imaging is often challenging for radiologists. We have demonstrated the CT and MR imaging findings of the mimics of gynecological masses include bowel or mesenteric origin (developmental cyst, neoplasm of colon or appendix, inflammatory mass), retroperitoneal origin (primary benign and malignant retroperitoneal tumors, lymphocele, lymph nodes), and peritoneal lesions (primary or secondary peritoneal tumor, peritoneal inclusion cyst, inflammatory mass) and others. It is important to understand the relationship of a mass with its anatomic location and identify normal ovaries at imaging to avoid misdiagnosis. Attention to these diagnostic clues is essential in making an accurate radiologic diagnosis of female pelvic masses and in obtaining clinically significant information.

P15-03 - PRIMARY HEPATIC MALIGNANT MESOTHELIOMA Serter A. 1, Pinarbasılı N. 1, Karatepe O. 1, Kocakoç E. 1 Bezmialem Vakif University Radiology Istanbul-Turkey 1

Objective: We present a case of primary hepatic malignant mesothelioma which is one of the rare liver tumors.

Case Presentation/Methods:56-year-old female patient presented with right upper quadrant pain and tenderness. Laboratory findings were unremarkable except anemia. Liver MRI and CT were performed. Multiphasic CT examination revealed a 15 x 11 x 10 cm hypodens mass involving entire segment 4A, 8 and 7 of the liver. There were hemorrhage, thick septations and central necrotic areas in the well-circumscribed lesion. The lesion was heterogeneous and hyperintens on the T2-weighted magnetic resonance imaging. On post-contrast images; peripheral serpiginous vascular structures were observed both CT and MRI. Also peripheral septal enhancement was seen which increased on the delayed images. The patient underwent surgical exploration and only biopsy was taken due to intraoperative findings of peritonitis carcinomatosa. Pathology result was epitheloid type hepatic malignant mesothelioma.

www.esur2013.org 194 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Results/ Discussion:Primary hepatic malignant mesotheliomas are heterogeneous large lesions with hemorrhagic contents, thick septations and necrosis. On post-contrast images peripheral serpiginous vascular structures, septal enhancement and increasing enhancement pattern periphery to central on delayed phase are typical for primary hepatic malignant mesothelioma. Two cases have been reported in the literature with similar characteristics before.

Conclusion:Primary hepatic malignant mesothelioma is very rare tumor of the liver. Preoperative diagnosis is difficult because of the radiological features not defined clearly. It can be misdiagnosed as large hemangiomas or angiosarcoma due to peripheral enhancement feature and hemorrhagic components.

195 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Poster Session 16 – Other Benign Urogenital Disorders

P16-01 - AN INTERESTING CASE ECTOPIC URETEROCELE AND IPSILATERAL RENAL AGENESIS Yildirim D. 1, Oruc F. 2, Yilmaz O. 3, Tutar O. 4 Centermed Advanced Imaging Center Radiology istanbul-Turkey 1 Istanbul Education And Research Hospital Radiology Istanbul-Turkey 2 GATA Haydarpasa Military Hospital Urology Istanbul-Turkey 3 Istanbul University, Cerrahpasa Hospital Radiology Istanbul-Turkey 4

Objective:Ectopic ureterecele and ipsilateral renal agenesis are rarely found together. In our case, due to ectopic flow and dilatation; the ureter had different fluid content than the urine inside the bladder. We aim to report this rare anomaly with its embryological and pathophysiological mechanisms in our presentation.

Material and Methods:The subject, who has suffered from dysuria continually over two years, has been scheduled for direct urinary system graphy, ultrasonography (US), magnetic resonance imaging (MRI), intravenous pyelography (IVP) and voiding cystourethrogram, and ureteroscopy exams, respectively.

Results:Right kidney could not be visualized during US imaging. In MRI and IVP images, the distal segment of the abnormal right ureter has ended in dilated ectopic ureterocele formation when the proximal site has terminated as blunt end. The distal part of it passed through the right seminal vesicle and reached the ectopic orifice at the inferior section of the bladder. No reflux developed inside ureterocele. Also, cystoscopy showed no ureterecole orifice.

Conclusion:During embryological phases, the obstruction of the distal ureter orifice can lead to total regression of metanephric blastema. The secretions that occur after this phase will cause formation of sequestrum inside the dilated ureter and/or ureterocele formation, which has different characteristics than the urine. Although somewhat similar cases were reported in literature, this study presents a unique case.

P16-02 - NON-MALIGNANT KIDNEY DISEASES USING LOW-DOSE 64 MULTIDETECTOR COMPUTED TOMOGRAPHY UROGRAPHY PROTOCOLS Al-Amin M. 1, Hadjidekov G. 2, Diakov I. 3 University Hospital Alexandrovska Department of diagnostic imaging Sofia-Bulgaria 1 Hospital Lozenets Department of Radiology Sofia-Bulgaria 2 National Centre of Radiobiology and Radiation Protection Sofia- Bulgaria 3

Objective: Computed tomography urography is one of the most advanced imaging modalities and became the mainstream methods in uroradiology in the new century. Although the risk of radiation exposure is different in patients population with non malignant kidney diseases, than patients with malignant.Our goal is to present the initial experience for the diagnosis of non malignant kidney diseases and congenital variants in the anatomy of the urinary system using low-dose protocols of research.

Method: There are different protocols based on the principles of ALARA. We have used three low-dose protocols of the study with no special preparation for the patients. We use three phases and late excretory one, after the introduction of contrast medium, using a single – bolus technique. Reconstructions are made on Maximim intensity projection and on Volume rendering.

Results: There are significant differences between the protocols, up to 81% dose reduction in measurable quantities CTDI and DLP, up to 60% dose reduction between the low-dose and ultra-low-dose protocols and up to 72 % reduction in effective dose which is estimation of radiation risk. At the same time the images obtained with the new low-dose protocols have maintained their diagnostic quality.

Conclusion: During CTU we received detailed examination of urinary tract, but it should be performed only in the cases when clinically required. As the radiation dose in an important issue, using low-dose and ultra- low-dose protocols of research we simultaneously save the image quality and reduce the radiation dose.

www.esur2013.org 196 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-03 - THE AMYAND’S HERNIA A RARE CLINICAL ENTITY DIAGNOSED BY COMPUTED TOMOGRAPHY Keskin S. 1, Şimşek C. 1, Keskin Z. 2 Necmettin Erbakan University, Meram School of Medicine Radiology Konya-Turkey 1 Konya Training and Research Hospital Radiology Konya-Turkey 2

Objective: The finding of vermiform appendix in inguinal hernia is called Amyand’s hernia. Appendix within inguinal hernias is uncommon, with a reported incidence varying from 0.28% to 1%. Traditionally, these hernias are diagnosed at surgery but now diagnosed by abdominal computed tomography scans. We present a rare case of inguinal hernia with presence of appendix in a 51-year-old man.

Method: A walnut-sized mass was found, located lower than the inguinal ligament. Severe pain was induced by direct compression. Physical findings revealed inguinal tenderness and rebound main in the right lower quadrant. There were no complaints of nausea, or vomiting. In this case of a suspected incarcerated hernia the hernia could not be reduced. CT was performed.

Results: The patient had increased white blood cell count (12 300/μL, with 82% neutrophils). CT revealed an appendix from pericecal area extended to the right inguinal channel. A small amount of fluid was present around with an appendiceal fecalith. The wall of appendix was thickened. At surgery, an inflamed appendix with appendiceal fecalith was found within the hernia sac. The appendix was removed and hernia repair was performed.

Conclusion: Radiologists need to be aware of the Amyand’s hernia. It is important to recognize both the inflamed and normal appendix within the inguinal canal, as well as abdominal complications. Amyand’s hernia is an extremely rare condition and is often misdiagnosed. CT of the abdomen may help in guiding the diagnosis as in our case.

P16-04 - URETERAL PSEUDODIVERTICULOSIS WITH FIBROEPITHELIAL POLYPS DIAGNOSED BY CT UROGRAPHY Kim M. 1, Kim Y. 1 Hanynag University Guri Hospital Radiology Guri-Republic of Korea 1

A 44-year old man was admitted to our urology department for evaluation of gross hematuria. He had no other clinical or laboratory abnormalities. CT urography revealed multifocal variable-sized (2-10mm) outpouchings of bilateral ureters. There was neither high attenuating calculi nor signs of obstruction. But multiple intra-ureteral enhancing lesions were noted adjacent outpouching areas of ureters on portal phase scans. For further evaluation, cystoscopy with retrograde pyeloureterography (RGP) for both ureters was recommended. Cystoscopic findings were not remarkable but RGP demonstrated multiple serpiginous filling defects which were seen or not seen on CT scans. Ureteroscopic biopsy for these filling defects was not performed and repeated urine cytology results were class I (normal) or II (benign atypia).

P16-05 - DIFFERENT SONOGRAPHIC APPEARANCE OF SCROTAL CALCULI TRILAMINARY AND BILAMINAR APPREANCE Artas H. 1, Saglam M. 1, Yıldırım I. 2, Ebıloglu T. 2, Gunal A. 3 Gulhane Military Medical Faculty Department of Radiology ANKARA-Turkey 1 Gulhane Military Medical Faculty Department of Urology Ankara-Turkey 2 Gulhane Military Medical Faculty Department of Pathology Ankara-Turkey 3

Objective:Scrotal calculi are benign entities, which are thought to represent freely mobile calcified bodies lying between the layers of the tunica vaginalis of the testes. The etiology of scrotal calculi is unclear. They may develop as sequelae to hematomas or inflammatory changes within the scrotum or loose bodies from torsion and infarction of the appendix testis or epididymis. Ultrasonography depicted the calculi typically as round or oval echogenic foci with or without acoustic shadowing. We presented the bilaminar and trilaminar appreance of scrotal calculi at ultrasonography that was not published in the medical literature yet.

197 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Method:Four patients (aged between 48 and 74 years) who had scrotal pain and swelling were sent to our clinic for ultrasonographic examination.

Results:At the scrotal ultrasound examination of these cases, calculi that freely moving, centrally calcified with around one or two soft tissue layer were detected. Calculi were bilaminar in three cases and trilaminar in one case. Calculi sizes were ranged from 5.4 to 10 mm. 74-year-old patient was operated for hydrocele. In this case, during the surgery, ultrasonographically identified lesion with freely moving, white hard, and round was seen and removed. This lesion was pathologically defined as collagenated and hypocellular scrotal nodular fibrous proliferation with focal dystrophic calcification.

Conclusion:Although the typical sonographic imaging features of scrotal calculi, bilaminar or trilaminar appreance of scrotal calculi might be considered.

P16-06 - HOW DO YOU URINATE PENILE AGENESIS WITH VESICORECTAL FISTULA Çolak f. 1, Ince s. 1, Kocaoğlu m. 1, Sağlam m. 1 Gulhane Military Medical Academy radiology ankara-Turkey 1

Objective: Penile agenesis is an extremely rare anomaly. In this entity during embryonic life genital tubercle is absent or fails to develop into a penis. Anomalies such as renal agenesis, horseshoe kidney, urethroanal fistula, imperforate anus and ventriculer septal defect may associate with penil agenesis.

Method: In this article, we aimed to present magnetic resonance(MR) and computed tomography(CT) findings of a 21-year-old male patient with penile and renal agenesis accompanying with vesicorectal fistula.

Results: On MR images seminal vesicles,right kidney were normal. Testes were present in the scrotal sac. Penis, left kidney, prostate gland and superior part of the left ureter were absent. Ureterocele was seen at the left vesicoureteral junction. On contrast enhanced CT there was a fistula coursing between the bladder and ventral part of the rectum.

Conclusion: Life threatening associated anomalies may be seen in cases with penile agenesis. Therefore, imaging modalities have crucial role to establish accurate diagnosis. Surgical procedures such as phalloplasty, urethroplasty or female gender assignment may be performed in early course of the disease to prevent possible disastrous psychosocial consequences.

P16-07 - RETROGRADE URETHROGRAPHY SPECTRUM OF ABNORMAL FINDINGS Jacob A. 1, George C. 2 University Hospital of North Staffordshire Imaging Stoke-on-Trent-United Kingdom 1 Univeristy Hospital of North Staffordshire Imaging Stoke-on-Trent-United Kingdom 2

Urethrography is a simple and valuable imaging tool in the investigation of various abnormalities suspected in the male urethra. We describe the procedural technique of urethrography and present a pictorial review of the various pathological imaging findings and also highlight the clinical management of these patients.

P16-08 - IMAGING APPEARANCES OF MAL-POSITIONED URETHRAL CATHETERS Evans R. 1, George C. 2, Gommersall L. 1 University Hospital of North Staffordshire Urology Stoke-on-Trent-United Kingdom 1 University Hospital of North Staffordshire Imaging Stoke on Trent-United Kingdom 2

Urinary catheter insertions are one of the commonly done medical procedures in both the community and hospital settings. Their insertion is in the majority of patients an uneventful episode. However mal-positioned catheter is inevitable in some patients due to suboptimal insertion or due to anatomical or pathological reasons. We present a pictorial review of the mal-positioned urethral catheter balloons in various anatomical locations highlighting the importance of identifying them so that they are rectified.

www.esur2013.org 198 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-09 - AN UNEXPECTED ULTRASONOGRAPHIC FINDING IN LITHIUM TREATED PATIENTS PERIPYRAMIDAL HYPERECHOGENITY Kavukcu G. 1, Kuman O. 2, Akdeniz F. 2, Yaprak M. 3, Sezis Demirci M. 3, Kocabas U. 4, Ozbek S. 1 Ege University School of Medicine Radiology Izmir-Turkey 1 Ege University School of Medicine Psychiatry Izmir-Turkey 2 Ege University School of Medicine Nephrology Izmir-Turkey 3 Ege University School of Medicine Endocrinology Izmir-Turkey 4

Objective: To describe a new sonographic finding of the kidney in lithium treated patients.

Method: Eighty-four lithium treated patients were selected for the study. They had no disease or drug use, other than lithium, effecting calcium metabolism. All patients with confounding factors which can cause hyper/hypocalcemia were excluded. The control group consisted of 30 healthy controls matched for age and sex who had never previously been treated with lithium and who do not use any pschotropic medication at least for the last six months. The ultrasonographic examinations of the kidneys were performed by two experienced radiologists who were blinded to the group of the subjects. High resolution ultrasound was used.

Results: Ten of the patient group and none of the controls had peripyramidal hyperechogenity representing early medullary nephrocalcinosis in both kidneys. Two of these 10 patients had scattered cortical echogenic foci. All of them had normal renal function tests, serum calcium and parathormon levels.

Conclusion: Tiny echogenic foci and cortical cysts have been reported before, in renal sonography of lithium treated patients. To our knowledge, this is the first report of a new sonographic finding: peripyramidal hyperechogenity.

P16-10 - CONGENITAL SEMINAL VESICLE CYST WITH IPSILATERAL RENAL AGENESIS Kalaycıoglu B. 1, Tanıdır Y. 2 Seka Govermental Hospital Radiology Ko-Turkey 1 Seka Govermental Hospital Urology Kocaeli-Turkey 2

Seminal vesicle cysts combined with genitourinary anomalies are uncommon. We present a 60-year-old married man who suffered from perianal and testicular pain with constipation.The symptoms were present in the last two years period but worsened at the last 6 months period. Abdominal sonography showed 59x17 mm lobulated cystic lesion at right perivesical location. The ipsilateral kidney and ureter were absent. As it is noted in the literature this patient also had ipsilateral vas deference agenesia. Since there were no laboratory abnormalities, patient received conservative medical treatment for both lower urinary tract symptoms and constipation.

P16-11 - DISTAL URETER STONE URACHAL CYST AND RETROAORTIC LEFT RENAL VEIN COOCCURRENCE US CT AND MRI FINDINGS Dilli A. 1, Ayaz U. 2, Turkkan M. 1, Hekimoglu B. 1 S.B. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi Radiology Ankara-Turkey 1 S.B. Mersin Kadın Doğum ve Çocuk Hastalıkları Hastanesi Radiology Mersin-Turkey 2

Objective: The purpose of the study is to present ultrasonography (US), colour Doppler ultrasonography (CDUS), computed tomography (CT), and magnetic resonance imaging (MRI) findings of a rare cooccurrence of urachal cyst localized in the anterior wall of the bladder and retroaortic renal vein variation which was diagnosed during the examinations for stone detected at the distal of the left ureter in an adult case, and to discuss the clinical significance of this coouccurrence.

Method: US, CDUS, CT and MRI examinations of a 37 years old male patient who had abdominal pain complaints were performed.

Results: A stone of size 6x5 mm was detected at the distal of the left ureter on US. In addition, on US and CDUS, it was determined that left renal vein elongated retroaortically and drained into vena cava inferior. In scrotal CDUS, a slight enlargement in vascular structures on the left side was observed, valsalva or reflux current were not observed. In the CT examination on the stone at the distal of the ureter, a hypodense cystic mass of dimensions 15x8 mm was detected at the anterosuperior of the hyperdense stone and bladder. Retroaortic left renal vein was also observed on CT. On MRI, hyperintense cystic mas was observed.

Conclusion: Since different variations and pathologies could be observed on the same case concurrently, imaging modalities should be used with suitable algorithms, and the images should be evaluated with the consideration of this probability.

199 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-12 - BILATERAL SUPERNUMERARY KIDNEY A VERY RARE PRESENTATION Keskin S. 1, Batur A. 1, Keskin Z. 2, Koç A. 1, Fırat Özcan İ. 1 Necmettin Erbakan University, Meram School of Medicine Radiology Konya-Turkey 1 Konya Training and Research Hospital Radiology Konya- 2

Objective: Bilateral supernumerary kidney is a very rare renal anomaly and to our knowledge there are five cases reported in the literature. The diagnosis of supernumerary kidney is difficult to make preoperatively and most cases have not been discovered until operation. Radiological evaluation including ultrasound (US) and computed tomography (CT) scan were done and the diagnosis was established. We present US and CT findings in a patient with bilateral supernumerary kidney.

Method: A 23-year-old man was admitted to the endocrinology department with hypertension for a year. Blood and urine analysis were within normal limits. US, Color doppler US and CT was performed.

Results: US showed bilateral lobulated kidneys and dilated collecting system. The renal parenchyma was normal on the US. The color Doppler study was performed but renal arteries were not showed because of gas artifact. CT confirmed the presence of bilateral supernumerary kidneys.There was fusion between the two kidneys on each side. Inferiorly located kidneys on each side had marked rotation anomaly and were smaller than superiorly located kidneys. Collecting system of all four kidneys was dilated. On each side, there were two renal arteries that arising from the abdominal aorta.

Discussion: Supernumerary kidney is an extremely rare renal anomaly, which affects both males and females equally.The diagnosis of supernumerary kidney is difficult to make preoperatively and most cases have not been discovered until operation. CT, and magnetic resonance imaging (MRI) can be used for diagnosis.

P16-13 - RELATIONSHIP BETWEEN KIDNEY VOLUME AND BODY INDEXES IN TURKISH POPULATION BY ULTRASONOGRAPHY Okur A. 1, Serin H. 1, Tanık S. 2, Zengin K. 2, Yıldırım U. 1, İmamoğlu H. 3, Erkoç M. 4 Bozok University Radiology Yozgat-Turkey 1 Bozok University Urology Yozgat-Turkey 2 Kayseri Research Hospital Radiology Kayseri-Turkey 3 Sivas Numune Hospital Radiology Sivas-Turkey 4

Objective: We estimated the kidney volume of healty Turkish population by using US and relationship between kidney volume and body indexes are evaluated.

Material and methods: Renal ultrasound evaluation was performed in 152 patients (mean age: 42±13.7 years years). Lenght, width and thickness of the kidney were measured by ultrasound. The mean total and parenchymal volume of kidneys were also calculated. Age, sex, weight,height and body mass index (BMI) values (kg/m2) of patients were recorded.

Results: As measured by ultrasound, kidney lengths were 10.3±7.8 cm for right and 10.4±9 cm for left, and kidney volumes were 158±39 cm3 for right and 168±40 cm3, and kidney volumes in women were 151.8±39 cm3 for right and 159.8±37 cm3 for left, and kidney volumes in men were 164.3±38 cm3 for right and 175.8±41 cm3 for left. Renal measurements were correlated with the body height and weight. The strong correlation with total renal volume and kidney measurements were found for body weight for both kidneys (p<0.001).The significant correlation with renal volume and kidney width was showed for both kidneys (p<0.001). A significant correlation was found between parenchym and total renal volume for both kidneys (p< 0.001).

Conclusion: Kidney volume is more correlates with weight of patients. There is strong correlation between kidney volume and kidney width was for both kidneys. Measuremets of kidney volume with US is useful modality and it has widely available for daily clinical practice.

www.esur2013.org 200 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-14 - THE CHANGING ROLE OF INTRAVENOUS UROGRAPHY EXPERIENCE IN A LARGE UROLOGY CENTRE Mathew A. 1, Salim F. 1, Kennish S. 1, Sak S. 1 Royal Hallamshire Hospital Imaging Department Sheffield-United Kingdom 1

Objective: To analyse the indications for intravenous urography (IVU) in current clinical practice and to compare with previous years.

Methods: All IVU performed during two separate 6-month periods (April 2010 to September 2010 [Phase 1] and November 2012 to April 2013 [Phase 2]) were retrospectively analysed. Data collected included indications, abnormalities detected including upper tract tumours, age of patient and quality of study.

Results: 318 IVU were performed in phase 1 (mean age 62.9 years, range 18-94) and 180 in phase 2 (mean age 62.5 years, range 17-95). Indications in phase 1 and phase 2 respectively, included haematuria (52% and 29%), post-cystectomy ileal conduit follow-up (14% and 33%), to check upper tract disease in newly diagnosed bladder TCC (20% and 17%), UTI (2% and 2%), loin pain (1% and 2%) and others (11% and 17%)

Conclusion: There has been a decline in the use of IVU within the space of 2 years. This is likely due to the increasing use of CT Urography to investigate haematuria. The commonest reason for performing IVU has changed from investigation of haematuria to assessment of ileal conduit.

P16-15 - FAT-CONTAINING LESIONS IN THE GENITOURINARY TRACT IMAGING PICTORIAL REVIEW Abedi-Farhad S. 1, James A. 1, Clark A. 1, George C. 1 University Hospital of North Staffordshire Imaging Stoke-on-Trent-United Kingdom 1

Objective:To demonstrate various macroscopic fat-containing lesions encountered in the genitourinary (GU) tract on cross-sectional imaging. To highlight the characteristics and clinical significance of these lesions to aid diagnosis such that patients are managed appropriately.

Method:This is a pictorial review of fat-containing lesions in the GU tract.

Result:Fat-containing lesions encountered within the GU tract in cross-sectional imaging are generally benign. However some may be malignant and it is important for radiologists to be aware of these lesions so that patients are managed appropriately.

Conclusion:Knowledge of imaging appearances and the clinical significance of fat-containing lesions will help radiologists provide an accurate diagnosis so that the patients may be managed appropriately.

P16-16 - FISTULAS OF THE GENITOURINARY TRACT IMAGING FINDINGS Kalkan H. 1, Ödev K. 1, Keskin S. 1, Özbek O. 1, Kılınç M. 2 Necmettin Erbakan University Meram School of Medicine Dept.of Radiology Konya-Turkey 1 Necmettin Erbakan University Meram School of Medicine Dept.of Urology Konya-Turkey 2

Objective: The aim of our study is to present twenty- five cases of genitoürinary fistulas.

Materials and Methods:From 1998 to 2013 twenty five cases (14 men, 11 women; age ranges: 2–84 y; mean age 48 y) of genitoürinary fistulas have been diagnosed and operated. Of these patients, 4 vesico-colic fistulas, 3 vesico-vaginal fistulas and 3 ürethral fistulas were repaired. The main symptoms of the patients with genitoürinary fistulas secondary to trauma, gynecologic or obstetric surgery (iatrogenic etiology) , chronic infections and neoplastic invasion are hematüria, ürinary incontinans and continous ürine leakage. The following procedures were utilized in the diagnosis of these fistulas: Intravenous urography (IVU)(n=10), retrograde cystography(n=4), voiding cystoürethrography(n=3), computed tomography(CT) (n=6) and MR imaging(n=9).

201 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Results:1 patient had reno-cutaneous fistula, 9 had üreteral fistula findings consistent with extravasation of contrast material into the retroperitoneum, 4 had üretero-intestinal fistula, 4 had vesico-colic fistula, 3 had vesico-vaginal fistula, 3 had ürethral fistula and 1 had vesico-prostatic fistula.

Conclusion:Genitourinary tract fistulas are diverse in their anatomy and clinical presentation. In addition to direct endoscopic techniqes and traditional contrast enhanced studies under floroscopy or radiography, cross- sectional modalities such as CT and MR imaging gained increasing support. The volumetric and multiplanar capabilities of CT and MR imaging may maximize diagnostic yield.

P16-17 - MULTIMODALITARY IMAGING FINDINGS OF MULLERIAN DUCT ANOMALIES Dagistan E. 1, Canan A. 1, Kizildag B. 2, Gurel S. 1 Abant İzzet Baysal University, School of Medicine Radiology Bolu-Turkey 1 Canakkale On Sekiz Mart University, School of Medicine Radiology Canakkale-Turkey 2

Objective: The aim of this paper is to illustrate the importance and diagnostic value of ultrasound (US) and magnetic resonance imaging (MRI) in detection and classificaton of mullerian duct anomalies (MDA).

Methods:Between January 2008 and June 2013, adolescents, with abdominal mass, pelvic pain or amenorrhea, and premenouposal women who underwent pelvic ultrasound and MRI for any other purposes and diagnosed as mullerian duct anomalies were retrospectively evaluated.

Results:The patients report a wide variety of symptoms such as dysmenorrhea, abdominal mass, as well as acute abdomen. US was performed for all the patients but it was not able to show whole pelvic structure and confirm the diagnosis of MDA. Hence, MRI were performed to evaluate pelvic organs, make the diagnosis, and classify Mullerian duct anomalies. In some patients renal anomalies were accompanying MDA.

Conclusion:Müllerian duct anomalies are a complex group of entities that result from the developmental disorders of the female genital tract with different presentations. Some of them are completely asymptomatic while some limit fertility and cause complications if not diagnosed and treated earlier. Although US is the first modality of evaluating female reproductive system, MRI is absolutely superior to US in patients with suspected MDA.

P16-18 - DORSAL PENILE VEIN ANEURYSM WITH DRAINAGE ANOMALY Erbay G. 1, Ozen M. 1, Eğilmez T. 2, Koc Z. 1, Karadeli E. 1 Baskent University Faculty of Medicine Radiology Adana-Turkey 1 Baskent University Faculty of Medicine Urology Adana-Turkey 2

We report a 31-year-old man with a dorsal penile vein aneurysm which is not surgery-related complication with a rare drainage variation . To our knowledge spontaneously growing dorsal penile vein aneurysm is seen very rare.

Patient came to Urology clinic with complaints of recurrent hematuria and progressive swelling of dorsum penis. On physical examination there was a fluctuating swelling at the radix penis. An aneurysm of left penile dorsal vein was seen in penile color Doppler sonography examination. Also venous very high insufficiency of left dorsal penile vein detected under valsalva maneuver.In CT angiography besides the aneurysm findings, it was seen that left penile dorsal vein was draining to a collateral vein of left vena saphena magna. Normally the primary drainage of the corpora cavernosa is into the deep dorsal vein and the internal iliac system.

Insufficient penile dorsal vein drainage to vena saphena magna with an aneurysmatic dilatation is a very rare condition. In our opinion aneurysm of dorsal penile vein can be related with the venous drainage anomalies or variation with high flow venous reflux.

www.esur2013.org 202 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-19 - EMPHYSEMATOUS CYSTITIS AS A POSSIBLE SIDE-EFFECT OF CYCLOPHOSPHAMIDE IMAGING FINDINGS Ünlü E. 1, Şahin M. 2, Yılmaz Ö. 1, Gözlek E. 1, Değirmenci B. 1 Süleyman Demirel University Radiology Isparta-Turkey 1 Süleyman Demirel University Rheumatology Isparta-Turkey 2

Objective: Emphysematous cystitis is a rare disease of urinary bladder. Aetiology is multifactorial and pathogenesis is poorly understood. Most patients are elderly diabetic females. We present the imaging findings of empysematous cystitis of a nondiabetic male with Wegener’s granulomatosis as a possible side- effect of cyclophosphamide.

Method: A 55-year-old male who was a known case of Wegener’s granulomatosis, presented in our rheumatology department with right hip pain and immobility. He was using cyclophosphamide and had no complaints of urinary system. X-ray of the right hip was suspicious for avascular necrosis (AVN) and MRI (magnetic resonance imaging) is performed. MRI revealed hypointensities along the urinary bladder wall and non-enhanced CT (computed tomography) is performed for better evaluation.

Results: MRI revealed the right femoral AVN and hypointensities along the bladder wall. CT demostrated the gas within the wall and lumen of bladder. Gas within the necrosis of the femoral head is detected interestingly. Looking at the X-ray again, circumferential air in the bladder wall is seen. Microscopic urinalysis showed red and white blood cells and some bacteria. The findings were consistent with emphysematous cystitis as a side effect of cyclophosphamide, because no other cause could be identified.

Conclusion: Genitourinary side effects of cyclophosphamide including hemorrhagic cystitis have been reported. But emphsematuos cystitis due to cyclophosphamide is unusual. The clinical presentation of emphysematous cystitis is nonspecific and ranges from asymptomatic urinary infection to urosepsis and septic shock. The diagnosis is made by abdominal imaging. Therefore, it is important to careful analysis of imaging findings

P16-20 - A GIANT RETROPERITONEAL URINOMA AFTER RADICAL CYSTECTOMY AND URINARY DIVERSION Kocak M. 1, Gurel S. 1, Dagistan E. 1, Olcun A. 1, Halicioglu S. 2 Abant İzzet Baysal University School of Medicine Radiology Bolu-Turkey 1 İzzet Baysal State Hospital Radiology Bolu-Turkey 2

Objective: To demonstrate the illustrative computed tomoghraphy urography (CTU) images of a giant retroperitoneal urinoma occured after radical cystectomy and urinary diversion and its resolution after an interventional therapeutic procedure.

Method:Due to low glomerular filtration rate, our routine CTU protocol was modified and then applied by simultaneous administration of non-ionic iodinated contrast from bilateral nephrostomy catheters for the patient whom was operated for invasive bladder carsinoma.

Results:CTU showed a giant perirenal fluid collection (measured as 10 HU) was detected. After administration of contrast through the nephrostomy catheters, marked opacification of fluid collection (100HU) occurred which was due to the injury of the right ureter, a complication of radical cystectomy and urinary diversion.

Conclusion:A urinoma is a cystic mass formed by extravasated urine. It may follow closed surgical operation, renal injury or arise spontaneously in the presence of obstruction. The essential factors are continued renal function, rupture of the collecting system and distal obstruction. Although a urinoma is typically located in the perirenal space, it may be seen in other locations, possibly as a result of disruption of a part of the ureter inferior to the perirenal space. CTU is the preferred method in evaluating the urine leaks and urinomas. Therefore, diagnostic imaging plays a significant role in prompt identification of urinary leaks and their cause.

203 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-21 - SPONTAN AIR DENSITY IN URINARY TRACT; SHOULD WE ALWAYS BE AGGRESSIVE Dagistan E. 1, Kizildag B. 1, Aydın M. 1, Gurel S. 1, Uyeturk U. 2 Abant İzzet Baysal University Radiology Bolu-Turkey 1 Abant İzzet Baysal University Urology Bolu-Turkey 2

Objective: Herein we report significant clinical and radiological findings of emphysematous pyelitis (EP) in a young man.

Methods:The patient had undergone abdominal radiography and excretory urography (EU) before admitting to our clinic for the history of renal calculus in a state hospital. The patient was underwent computed tomography urography (CTU).

Results:A 22-year-old man is referred to urology department for persistent pain in the right flank and dysuria for the last 6 days. His medical record revealed right nephrolithiasis but was negative for DM and other systemic diseases. CTU revealed slimming of renal parenchyma and enlargement of the right kidney due to hydronefrosis. A staghorn calculus was localized in the upper collecting system and numerous subcentrimetric calculies in the calices of inferior pole. Marked right renal caliceal distortion and ectasia accompanying air-fluid levels were also noted. Gas bubbles were depicted both in the right ureter and non-dependent bladder lumen as well.

Conclusion:The diagnosis and treatment of EPN must be prompt due to its high mortality rates. The management includes drainage or nephrectomy following antibiotherapy. On the other side EPN; EP has lower mortality rates with only medical treatment. Therefore gas forming renal infections necessitates early diagnosis and management. Radiologists and clinicians must be aware of differential diagnosis of EP from EPN in order to avoid unnecessary interventional procedures or surgery.

P16-22 - ANTICOAGULANT RELATED INTRAMURAL HEMATOMA OF THE RENAL COLLECTING SYSTEM Acu B. 1, Gökçe E. 2, Kurtuluş E. 1, Beyhan M. 2, Kara T. 1, Çoraklı M. 2 Osmangazi University Medical Faculty Radiology Eskişehir-Turkey 1 Gaziosmanpasa University Medical Faculty Radiology Tokat-Turkey 2

Objective: Anticoagulants, including heparin, low-molecular-weight heparins and warfarin, are currently used for the treatment of cardiovascular, cerebrovascular and pulmoner diseases.Hemorrhage is a serious complication of anticoagulant therapy, is reported in 4% of treated patients.We aim to present US,CT and MRI findings of a intramural hematoma of the right renal collecting system under anticoagulant therapy.

Method: A 58year-old female patient presented with back pain who referred to radiology department. Personal history of the patient revealed mitral valv replacement surgery .He was under treatment with warfarin.Laboratory findings were normal except for decreased hemoglobin and hematocrit values and high INR.US, CT and MRI examinations were performed to the patient.

Results: US examination demonstrated diffuse wall thickening of both right renal pelvicalyceal system and right ureter. Non-contrast CT scan showed hyperdense diffuse wall thickening of both right renal pelvicalyceal system and right ureter and linear increased perirenal and periuretheral fat density. These findings confirmed with MRI.Considering with the physical examination, history, laboratory values and radiologic imaging these findings were compatible with a intramural hematoma of the right renal collecting system under anticoagulant therapy.

Conclusion:Anticoagulant related renal hematomas usually presents with hematuria, flank pain mimicking renal colic.The hemorrhage may be intraparenchymal, perinephric, subcapsular, suburothelial within the renal sinus.During acute phase on CT hematoma is seen hyperdense.Anticoagulant related renal hematomas can mimic renal masses.Thus contrast-enhanced CT and serial follow-up can exclude the undergoing mass.

www.esur2013.org 204 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-23 - AN ATYPICAL AND HUGE PYELOCALYCEAL CYST (DIVERTICULUM) THE GREAT MIMICKER! Gürel S. 1, Celdirme E. 1, Gürel K. 1, Gur S. 1, Dagistan E. 1 Abant İzzet Baysal University Radiology Bolu-Turkey 1

Objective:To present findings of ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI) and floroscopic interventional examination of a male patient who has an atypical pyelocalyceal cyst mimicking a Bosniak type 2F cortical cyst.

Methods:A 29 year-old male patient who had chronic nephrolithiasis history and renal cysts, was being investigated because of a renal cyst, larger than 5 cm, to determine the Bosniac cathegory. The patient underwent urinary system USG, CT urography, contract enhanced dinamic renal MRI examinatons and a fluoroscopy guided percutaneus drainage procedure.

Results:7 cm renal cyst, which has no opacification during CT or MRurography and thought as a cortical cyst, came out to be a pyelocalyceal cyst during taking the control images for floroscopy guided percutaneus drainage procedure.

Conclusion:Pyelocalyceal cyst (also called Pyogenic Diverticulum) is a urine-containing cyst within renal parenchyma, communicating with collecting system through a narrow channel. Usually it is asymptomatic and small. Most will opacify during urogram phases of CT/MRI owing to the connection with collecting system which is diagnostic. But if there is stricture or inflammation of the connecting channel and obstruction, then it might be difficult to differentiate from other cystic renal lesions. In that case diagnosis is important because it is a benign condition which does not require surgical intervention and prevention of application of ablative (i.e. alcohol as in our case) interventional techniques to the lesion that is indeed not a cortical cyst.

P16-24 - MAGNETIC RESONANCE IMAGING FINDINGS OF SYMPTOMATIC PARAURETHRAL CORPUS SPONGIOSUM CYST Acu B. 1, Gökçe E. 2, Kurtuluş E. 1, Beyhan M. 2, Kara T. 1 Osmangazi University Medical Faculty Radiology Eskişehir-Turkey 1 Gaziosmanpasa University Medical Faculty Radiology Tokat-Turkey 2

Objective: Symptomatic paraurethral cysts of the posterior urethra in men are so rare.Only five cases have been reported in the English literature which are similar to our case.In healthy young men nonspecific lower urinary tract symptoms and flow rate reduction, it should be considered in the differantial diagnosis.We aimed to present the MRI findings of the paraurethral corpus spongiosum cyst-Littre’s gland cysts.

Method: A 47 year old man admitted to the department of urology with the complaint of dysuria which had been for 3 months.Also he had frequency of micturition, postvoid dribbling, and reduced urinary flow.There was no history of trauma or urinary tract infection.Blood chemistry values were in normal limits.Then the patient investigated with pelvic MRI

Results:On the pelvic MRI at the level of bulbous urethra, periurethral area of the corpus spongiosum a well- defined, fusiform shaped, 7x5 cm mass with regular contour which was shown as hypointense signals on T1WI and hyperintense signals on T2WI.This lesion reported as paraurethral corpus spongiosum cyst-Littre’s gland cyst.

Conclusion:Urethral diverticula and cysts are uncommon in men.Acquired urethral diverticula in men can be seen following trauma and urethroplasty.But diverticula or cysts of the male urethra of non traumatic origin are so rare.As this case demonstrates in an otherwise healthy young man a paraurethral spongiosal cyst can reduce urinary flow and cause nonspesific urinary symptoms.So after excluding other conditions,paraurethral corpus spongiosum cyst should be considered as a differential diagnosis in persistant lower urinary tract symptoms in young men.The diagnosis is best made with MRI.The mainstay

205 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

P16-25 - GIANT BLADDER DIVERTICULUM MIMICKING CYSTIC ABDOMINAL MASS Gürel S. 1, Celdirme E. 1, Kocak M. 1 Abant İzzet Baysal University Radiology Bolu-Turkey 1

Objective: To present computed tomography (CT) findings of a giant bladder diverticulum which presented with hydrouretheronephrosis.

Methods:A 60 year-old male patient who prostatism symptoms was performed sonography was diagnosed with hydrouretheronephrosis and a pelvic cystic mass. We evaluated with CT urography.

Results:A 14 cm cystic lesion connected to the bladder with a narrow neck found to be a giant diverticulum. As it compreses the uretherovesical junction, hydrouretheronephrosis was occured.

Conclusion:Bladder diverticulum is the mucosal herniation through the muscle wall but maintains its continuity with the bladder, often by a narrow neck. It can be primary (associated with vesicoureteral reflux); secondary (associated with bladder outlet obstruction); or congenital. In adults, it can mimic pelvic cystic masses. Bladder diverticulum may contain calculi and malignant neoplasms secondary to chronic inflammation. The mass effect can also cause the clinical symptoms.

P16-26 - A RARE INGUINAL HERNIA CONTENT BLADDER AND BLADDER CALCULI Parlak S. 1, Altın L. 1, Ozsoy A. 1, Kaplanoglu V. 1, Kaplanoglu H. 2, Deveer M. 3 Numune Education and Research Hospital Radiology Ankara-Turkey 1 Dıskapı Yıldırım Beyazıt Education and Research Hospital Radiology Ankara-Turkey 2 Mugla University Faculty of Medicine Radiology Mugla- Turkey 3

Although inguinal hernias involving intestine are frequent in the general population, infrequently contents of hernias may be appendix, ovary, uterus and bladder. We present a case of bladder hernia accompanying bladder stone to the left inguinal canal.

A 52 years old male patient was referred to our clinic for urinary complaints and intermittant bulging in the groin. Bladder herniation to left inguinal canal was detected by ultrasound and unenhanced multidetector computed tomography. There was a 2,5 cm sized calculi inside the herniated bladder.

Bladder hernias are 1-4% of inguinal hernias in the general population. Most cases are asymptomatic but, large hernias may present with inguinal bulging and lower urinary symptoms. It is also important because of probability of renal failure complication. Bladder outlet obstruction, overdistended bladder, pelvic wall weakness, obesity and advanced age are the possible pathophysiologic conditions. Ureter can accompany to bladder, and calculi can develop secondary to urinary stasis. Surgical repair is the standard treatment. There are several cases about bladder herniation in the literature. But bladder herniation with calculi cases are few. Our goal is to present very rare case inguinal hernia involving bladder and bladder stone.

P16-27 - ASSOCIATION BETWEEN CYSTIC KIDNEY DISEASE AND METABOLIC SYNDROME Karabacak O. 1, Karakoyunlu A. 1, Dilli A. 2, Yeşil S. 3, Topaloğlu H. 1 Ministry of Health Ankara Dışkapı Yıldırım Beyazıt Education and Research Hospital Urology Ankara-Turkey 1 Ministry of Health Ankara Dışkapı Yıldırım Beyazıt Education and Research Hospital Radiology Ankara- Turkey 2 Gazi University Medical Faculty Urology Ankara-Turkey 3

Purpose:The purpose of this study is to examine the association between renal cyst and metabolic syndrome comparing the patients diagnosed with renal cyst with a control group.

Material And Method:The study included 250 cases who were admitted to the urology clinic for various complaints and were diagnosed with renal cyst by ultrasonography or tomography, and a healthy control group of 100 individuals with similar age as the study group. The height, weight, waist circumference, and blood pressure measurements were obtained. Glucose, blood lipids, urea, creatinine values were assessed by 12 hour fasting blood tests.

National Cholesterol Education Program Adult Treatment Panel 3 criteria were used in the evaluation of the patients.

www.esur2013.org 206 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Results:It was determined that the demographic information of the patients were similar, and the mean age of study group and control group were 60.34 and 58.72 respectively. Mean waist circumference of the study group and control group were 97.86 and 99.73, and body mass indexes 28.8 and 28.3 respectively. (Table 1)

Metabolic syndrom according to NCEP-ATP3 was detected in 28/99 which was statistically significant (p=0.041). The incidences of low HDL and high triglyceride were higher in the study group than the control group which was also statistically significant. (Table 2)

Conclusion:It could be concluded from these findings that the metabolic syndrome -although its pathophysiology is not clear,it has been proved to be coexisting with many diseases- is seen more frequently in renal cyst patients than the healthy individuals.

P16-28 - SPONTANEOUS RIGHT SIDED THROMBOSIS OF THE PAMPINIFORM PLEXUS Aksoy O. 1, Turgut A.T. 2, Günbey H. 1, Tayfun F. 1 Çankırı State Hospital Department of Radiology Çankırı-Turkey 1 Ankara Training and Research Hospital Department of Radiology Ankara-Turkey 2

Introduction:Spontaneous thrombosis of the pampiniform plexus is a very uncommon clinical entity. We presented a case of pampiniform plexus thrombosis that was diagnosed as epididymo-orchitis.

Case: A 34-year-old male was evaluated for the sudden onset painful mass in the right hemiscrotum. He was initially diagnosed as epididymo-orchitis. After receiving antibiotic treatment, he came back later with nonresolving pain and swelling. At CDUS examination, testis and the epididymis were found to be normal and a hypoechoic , heterogeneous, noncompressible and nonvascular mass with dimensions of 20.5x9.7 mm which was isoechoic with thrombosed pampiniform plexus veins was detected next to the tail of the epididymis. On MRI, the lesion was isointense on T1-weighted and hypointense on T2-weighted compared with epididymis. The lesion was diagnosed as thrombosis of the pampiniform plexus. The patient received enoxaparin treatment . On follow-up US the size of the mass was decreased and CDUS revealed minimal venous blood flow within the mass.

Conclusions:Spontaneous thrombosis of the pampiniform plexus is a rare clinical problem, with only 15 cases reported in the literature and a single report of bilateral involvement. All cases,except one, involved the left side. In a similar fashion, a right side involvement was noted in the the present case.

The entity may mimic emergent scrotal and inguinal conditions and almost always has a benign course. Although surgery may be considered with a suspicion of complicated inguinal hernia, a detailed US examination can provide an accurate diagnosis and prevent an unnecessary surgical intervention. Notably, MRI can be helpful in equivocal cases.

207 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY AUTHOR LIST

Author Name Page Author Name Page Abou El-Ghar M. 24, 186 Caseiro-Alves F. 46 Acar T. 142 Celikkanat S. 137 Acu B. 149,161, 193, 204, 205 Chandarana H. 70 Afifi -hafez A. 98, 111,125,165 Chingkoe C. 157 Akata D. 38 Choi H. 139 Akhan O. 85 Chong W. 80 Aksoy O. 207 Claudon M. 79 Al-Amin M. 155, 180, 196 Claus F. 44 Alt C. 23, 24 Cohan R.H. 40 Altay C. 110, 142 Colak E. 78 Altın L. 193 Cornelis F. 63 Altug F. 40 Cornud F. 36 Apaydın D. 177, 178, 181 Correas J.M . 69 Arıoz H. 182 Cova M. 43 Artas H. 128,154 , 177, 197 Cunha T.M. 40 Atay M. 100 Çolak F. 198 Atci N. 132, 157 Çolakoğlu Er H. 100 Ateş Kadıoğlu 89 Dadalı Y. 185 Atuğ F. 42 Dahlman P 26 Ayaz U. 123 Danacı M. 160,162 Aydın M. 160 Danza F.M. 30 Balleyguier C. 41 Darge K. 52 Balyemez F. 144 De Wever L. 44 Barentsz J. 37 Demir P. 93,145 Başara I. 156 Derchi L.E. 71 Behairy N. 106 Dilli A. 155, 156, 157, 199, 206 Bekin S.P. 122 Djavan B. 36 Bellin M.F. 31, 49 Dogra V. 48, 72 Benmoussa R. 187 El-Diasty T. 59, 145, 149 Berkenblit R. 125 El-Ghar M.A. 85 Bertolotto M. 28, 82 EL-Shater B.A. 67, 168,172 Bharwani N. 56 Emre Salabaş 89 Bilgili Y. 162 Erbay G. 92, 93, 115,134,150 Bongartz G. 49, 122 Fırat H. 117 Botsikas D. 20 Forstner R. 39, 58 Boussalah M. 151, 152, 173, 175 Futterer J. 34 Brkljačić B. 78 Gaitini D. 77 Cacchiarelli E. 176 George C. 26, 101, 141, 143, 198, 201 Cakir O. 174 Gervaise A. 179 Cakir P.B. 131,19 Gezer N. 113 Canda A.E. 84 Gokan T. 138 Carbone S. 116 Gregertsen K. 101 Cardone G. 169,17 Grenier N. 25, 33, 63, 69

www.esur2013.org 208 European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Author Name Page Author Name Page Gunes T.I. 120 Lee H. 166, 167 Gurel S. 149,182,192,202, Lee Y. 130, 131, 194 203,204,205,206 Lerut E. 44 Hadjidekov G. 136, 164 Lhommé C. 39 Haider M. 34 Lim K. 125 Haie-Meder C. 39 Løgager V. 36, 42 Haliloğlu M. 55 Lyall H. 97 Hanna S. 72 Maes B. 121 Harvey H. 101 Masselli G. 87 Heilburn M. 40 Mazher H. 183 Heinz-Peer G. 74 Moon M. 21 Helenius M. 23 Moon S. 143, 164, 185 Inan I. 146 Morcos S.K. 49 Incedayı M. 112 Mossad M. 181 İnan N. 126 Moussa S. A. 66 Junker D. 96 Naggara T. 58 Kafadar C. 187 Newhouse J.H. 86 Kalaycıoglu B. 186, 199 Niknejadi M. 191 Kara T. 135, 144 Nikolaidis P. 74 Karlo C. 19 Nori M. 190 Keanie J. 60 Notohamiprodjo M. 70 Keçeci İ. 128 Ntoulia A. 52 Kekelidze M. 189 Nural M. 130 Kenney P.J. 76 Nurili F. 148 Keskin S. 137, 153,175,197,200 Oh Y. 163 Kılıc D. 131,133 Okur A. 200 Kielar A. 19 Onur R. 27, 77 Kilic F. 136 Oyar O. 179 Kilicoglu Z. 150 Oyen R. 44 Kim K. 94 Ozbek S. 199 Kim M. 143,197 Ozen M. 202 Kim S. 168,169 Ozkavukcu E. 192 Kim S.H. 29 Ozmen M. 40 Kim Y. 126 Ödev K. 174, 176, 184, 201 King A. 103 Özkul B. 106 Kirkham A. 34 Panebianco V. 36, 152, 173 Kismali E. 21 Pansini M. 109 Kocakoç E. 60 Papadopoulou F. 52 Koç U. 140 Park S. 127 Koplay M. 190 Parlak S. 110, 151, 206 Kulali F. 99 Paspulati R.M. 68 Kuroda I. 164 Patel C. 113 Kuru T. 114 Pavlica P. 91 Laghi A. 49 Pekindil G. 134, 147, 148 Lay J. 146 Pekoz B. 171 Lee E. 117 Petralia G. 114,172

209 www.esur2013.org European Symposium on Urogenital Radiology “Oncologic Imaging of the Urogenital System” September 19 - 22, 2013 Istanbul - TURKEY

Author Name Page Author Name Page Picker W. 97 Villeirs G. 37 Ramchandani P. 71 Vos E. 22 Regier M. 96, 109 Wadhwani S. 166, 171 Rha S. 93,131 Wah T. 102, 104 Riccabona M. 52,54 Wahba M. 118 Richenberg J. 36 Walz J. 67 Rocher L. 19 Willi U. 52 Rockall A. 39 Yağcı B. 159 Roethke M. 95 Yamamoto A. 99 Rona G. 159 Yetis H. 121 Roy C. 27, 61 Yılmaz Ö. 183, 186, 187, 203 Saglam M. 176 Yildirim D. 153,180, 196 Salamati M. 154 Yoon S. 141 Salim F. 123, 201 Zaheer A. 59 Saoud S. 188 Zhukov O.B. 111,12 Sebastia C. 139,155 Secil M. 14, 81 Serter A. 194 Studniarek M. 116 Sung D. 138,159 Şanlı Ö. 33 Şimşek B. 107 Şirin Ö.A. 119 Takahama J. 124 Tamada T. 95 Tanrıvermiş S.A. 107,108 Tanter M. 69 Tarhan N. 129 Tarhan N.C. 58 Tatcı E. 147 Thomsen H.S. 51 Tıraş B. 88 Titorenko R. 100 Tricaud E. 25 Tsili A. 20, 139 Tsuda M. 127 Tuncel S. 163 Turkbey B. 34 Tutar O. 174 Unal O. 105 Uzan C. 39 Üstüner E 118,129 Van Poppel H. 44 Vanhooymissen I. 22 Verma S. 36 Vikram R. 59

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