- Email: [email protected]
Diagnostic Imaging for Pediatric Scrotal Disorders
IMAGING
Several statements in this article are worth repeating. A contrast evaluation of a ureteral stent placement is recommended if there is heavy bleeding after nephrostomy because the stent may occlude with clots. The most common location of ureteral obstruction was the ureteroneocystostomy site. The reasons for this occurrence are reviewed and the best results of stent placement were in this location. The success rate of stent placement did not seem to be affected by the severity of obstruction but there was a significant correlation with whether the obstruction was late (greater than 3 months). Higher success rate with early treatment is related to the etiology of the obstruction. Treatment of late lesions is less successful because these narrowings tend to have a significant amount of fibrosis. The authors also report success in 4 of 5 leaks, which were treated within the first 6 weeks after transplantation. In 1case surgery was done the day after stent placement because the surgeon believed that there might have been complete disruption of the anastomosis. This case may well have been a success with followup. This series clearly indicates that even when stent placement is unsuccessful, salvage procedures, including surgery and so forth, are usually successful. Recent endourological techniques are becoming more sophisticated and successful, and time will tell if these techniques will replace stent placement. Currently, to my knowledge no comparative studies exist. Stanford M. Goldman, M.D.
Nonmalignant Renal Disease in Pediatric Patients With Beckwith-WiedemannSyndrome
P. L. CHOW, M. J. SIEGEL, 0. OZ, C. SOTELO-AVILA AND M. R. DEBAUN, Department of Radiology, Clinical Center, and Genetic Epidemiology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, Department of Radiology, University of Texas, Southwestern Medical Center at Dallas, Dallas, Texas, Mallinckrodt Institute of Radiology, and Department of Pathology, Cardinal Glennon Children’s Hospital, St. Louis, Missouri AJR, 171: 733-737, 1998 OBJECTTVE. The objective of this retrospective review was to determine the incidence and spectrum of nonmalignant renal disease in patients with Beckwith-Wiedemann syndrome. MATERIALS AND METHODS. Patient records were obtained from the Beckwith-Wiedemann Registry of the National Cancer Institute. Imaging findings and medical records of 152 neonates, infants, children, and adults with Beckwith-Wiedemann syndrome (age range, 1 day to 30 years old; median age, 1year 3 months old) were retrospectively reviewed by three radiologists. Available pathologic material also was reviewed. RESULTS. Thirty-eight (25%) of 152 patients with Beckwith-Wiedemann syndrome had 45 nonmalignant renal abnormalities, including medullary renal cysts ( n = 19, 13%), caliceal diverticula ( n = 2, l%), hydronephrosis (n = 18, 12%), and nephrolithiasis tn = 6,4%).Thirty-three (8’7%)of the 38 patients with nonmalignant renal disease were asymptomatic. Clinical manifestations of the remaining five patients, included unnary tract infections (n = 4) and flank pain due to obstructive stone disease (n = 1).Nonmalignant renal disease was mistaken for Wilms’ tumor and nonmalignant renal disease. CONCLUSION. Nonmalignant renal abnormalities occur in approximately 25% of patients with Beckwith-Wiedemann syndrome but are generally asymptomatic. Nonmalignant renal abnormalities should be considered in the differential diagnosis of a mass revealed during screening sonography of a patient with Beckwith-Wiedemann syndrome to avoid unnecessary surgery. Editorial Comment: The authors reviewed the patient records of the Beckwith-Wiedemann registry at the National Cancer Institute. The records included 152 patients 1 to 30 years old (median age 1 year 3 months). Of these patients 38 (25%) actually had 45 nonmalignant renal processes, including medullary cysts (19),caliceal diverticula (2), hydronephrosis (18) and nephrolithiasis (6). Of these patients 33 (87%) were asymptomatic when the abnormality was discovered and the remainder had varying symptoms, including urinary tract infection in 4 and flank pain due to obstructive stone disease in 1. In 2 of these patients n e p k t o m y was performed for suspected Wilms tumor when in fact the patients had nonmalignant renal disease. The most important message in this study is the recognition that not all renal pathology in patients with the Beckwith-Wiedemann syndrome is secondary to Wilms tumors, and that adequate evaluation clinically and radiographically is important before surgery is performed. Stanford M. Goldman, M.D.
Diagnostic Imaging for Pediatric Scrotal Disorders
D. P. FRUSH AND C. A. SHELDON, Department of Radiology, Duke University Medical Center, Durham, North Carolina, and Department of Urology, Children’s Hospital Medical Center, Cincinnati, Ohio RadioGraphics, 18: 969-985, 1998 Classification of pediatric scrotal disorders into three typical clinical manifestations-acute scrotal disorders, scrotal masses, and cryptorchidism-provides a practical basis for evaluation with the most
1401
1402
IMAGING
commonly used modalities-sonography, scintigraphy, and magnetic resonance (MR) imaging. Acute scrotal disorders of children include acute epididymitis, torsion of an appendix testis or appendix epididymis, and torsion of the spermatic cord. Either scintigraphy or sonography may be used as the first imaging study, and both can aid in distinguishing among the disorders to different degrees. However, sonography is becoming the preferred modality, primarily because of the superior anatomic detail provided. Scrota1 masses are also best depicted with sonography, although MFi imaging can occasionally be a useful adjunctive modality. In cases of suspected cryptorchidism with equivocal clinical findings, both sonography and MR imaging may be useful, although sonography is usually the initial study. Knowledge of characteristic imaging appearances, as well as benefits and limitations of the available modalities, enables appropriate, expeditious radiologic evaluation of pediatric scrotal disorders.
Editorial Comment: On a monthly basis, RadioGmphics, which is published by the Radiological Society of North America, has excellent imaging review articles mostly culled from the scientific exhibits at their annual meeting. Usually anywhere from 1 to 4 articles are devoted to genitourinary topics and I strongly recommend them. The authors clearly review the multiple imaging modalities that are available for evaluation of the scrotum. They also review the entities that can be readily imaged and diagnosed as common scrotal abnormalities in the pediatric population. Acute scrotal disorders are reviewed including a pediatric case of a scrotal mass. Stanford M. Goldman, M.D.
Cystosonography With Echocontrast: A New Imaging Modality to Detect Vesicoureteric Reflux in Children M. BOSIO,Paediatric Department, Magenta Hospital and Advanced School of Paediatric Ultrasonography, Magenta, Italy Ped. Rad., 25: 250-255, 1998 Abstract Printed in J. Urol., 160 1592, 1998 Editorial Comment: The current gold standard for demonstrating significant reflux is the voiding cystourethrogram. However, this study exposes the child to radiation. Radionuclide cystography exposes the patient to less radiation and reveals significant reflux. However, it fails to show the anatomical abnormality that may underline the reflux, such as urethral valves in the male patient. The authors studied whether ultrasonic techniques using an echo contrast medium could be substituted for the current gold standard and, thus, obviate exposure to radiation. A total of 58 neonates were studied with a galactose suspension. These studies were compared to voiding cystourethrography and radionuclide cystography. It should be noted that not all patients had all 3 studies performed. The reasons for the evaluations included pyelectasis in 21 cases and pyelonephritis in 37. Echo sonography detected 76 refluxing units in 50 patients. Eight patients did not undergo voiding cystourethrography. In 43 patients voiding cystourethrography or radionuclide cystographydetected 62 refluxing units. Thus, the authors believe that echo sonography yields results comparable to voiding cystourethrography. If these excellent results are confirmed by others, one could seriously accept echo sonography as an adequate substitution for radionuclide cystography as the study of choice to following these cases. Although the authors claim that echo sonography did not fail to detect any anatomical variance, such as paraureteral diverticula, ureteroceles and duplication anomalies, I believe that posterior urethral valves can still be missed. Therefore, I would recommend that the initial study still be voiding cystourethrography. Stanford M. Goldman, M.D.
US,CT and MFt Imaging Characteristics of Nephroblastomatosis W. K. ROHRSCHNEIDER, A. WEIRICH, K. RIEDEN, K. DARGE, J. TROGER AND N. GRAF,Departments of Pediatric Radiology and Radiology, University of Heidelberg, Heidelberg, Heidelberg, and Department of Paediatric Oncology, Children’s Hospital, University of HomburglSaar, Hamburg, Germany Ped. Rad., 2 8 435-443, 1998 Objectives. To describe the imaging features of nephroblastomatosis with US, CT and MR, to point out characteristics of differentiation between nephrogenic rests (NR) and Wilms’ tumour (WT) and to determine the most appropriate imaging modality.
Several statements in this article are worth repeating. A contrast evaluation of a ureteral stent placement is recommended if there is heavy bleeding after nephrostomy because the stent may occlude with clots. The most common location of ureteral obstruction was the ureteroneocystostomy site. The reasons for this occurrence are reviewed and the best results of stent placement were in this location. The success rate of stent placement did not seem to be affected by the severity of obstruction but there was a significant correlation with whether the obstruction was late (greater than 3 months). Higher success rate with early treatment is related to the etiology of the obstruction. Treatment of late lesions is less successful because these narrowings tend to have a significant amount of fibrosis. The authors also report success in 4 of 5 leaks, which were treated within the first 6 weeks after transplantation. In 1case surgery was done the day after stent placement because the surgeon believed that there might have been complete disruption of the anastomosis. This case may well have been a success with followup. This series clearly indicates that even when stent placement is unsuccessful, salvage procedures, including surgery and so forth, are usually successful. Recent endourological techniques are becoming more sophisticated and successful, and time will tell if these techniques will replace stent placement. Currently, to my knowledge no comparative studies exist. Stanford M. Goldman, M.D.
Nonmalignant Renal Disease in Pediatric Patients With Beckwith-WiedemannSyndrome
P. L. CHOW, M. J. SIEGEL, 0. OZ, C. SOTELO-AVILA AND M. R. DEBAUN, Department of Radiology, Clinical Center, and Genetic Epidemiology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, Department of Radiology, University of Texas, Southwestern Medical Center at Dallas, Dallas, Texas, Mallinckrodt Institute of Radiology, and Department of Pathology, Cardinal Glennon Children’s Hospital, St. Louis, Missouri AJR, 171: 733-737, 1998 OBJECTTVE. The objective of this retrospective review was to determine the incidence and spectrum of nonmalignant renal disease in patients with Beckwith-Wiedemann syndrome. MATERIALS AND METHODS. Patient records were obtained from the Beckwith-Wiedemann Registry of the National Cancer Institute. Imaging findings and medical records of 152 neonates, infants, children, and adults with Beckwith-Wiedemann syndrome (age range, 1 day to 30 years old; median age, 1year 3 months old) were retrospectively reviewed by three radiologists. Available pathologic material also was reviewed. RESULTS. Thirty-eight (25%) of 152 patients with Beckwith-Wiedemann syndrome had 45 nonmalignant renal abnormalities, including medullary renal cysts ( n = 19, 13%), caliceal diverticula ( n = 2, l%), hydronephrosis (n = 18, 12%), and nephrolithiasis tn = 6,4%).Thirty-three (8’7%)of the 38 patients with nonmalignant renal disease were asymptomatic. Clinical manifestations of the remaining five patients, included unnary tract infections (n = 4) and flank pain due to obstructive stone disease (n = 1).Nonmalignant renal disease was mistaken for Wilms’ tumor and nonmalignant renal disease. CONCLUSION. Nonmalignant renal abnormalities occur in approximately 25% of patients with Beckwith-Wiedemann syndrome but are generally asymptomatic. Nonmalignant renal abnormalities should be considered in the differential diagnosis of a mass revealed during screening sonography of a patient with Beckwith-Wiedemann syndrome to avoid unnecessary surgery. Editorial Comment: The authors reviewed the patient records of the Beckwith-Wiedemann registry at the National Cancer Institute. The records included 152 patients 1 to 30 years old (median age 1 year 3 months). Of these patients 38 (25%) actually had 45 nonmalignant renal processes, including medullary cysts (19),caliceal diverticula (2), hydronephrosis (18) and nephrolithiasis (6). Of these patients 33 (87%) were asymptomatic when the abnormality was discovered and the remainder had varying symptoms, including urinary tract infection in 4 and flank pain due to obstructive stone disease in 1. In 2 of these patients n e p k t o m y was performed for suspected Wilms tumor when in fact the patients had nonmalignant renal disease. The most important message in this study is the recognition that not all renal pathology in patients with the Beckwith-Wiedemann syndrome is secondary to Wilms tumors, and that adequate evaluation clinically and radiographically is important before surgery is performed. Stanford M. Goldman, M.D.
Diagnostic Imaging for Pediatric Scrotal Disorders
D. P. FRUSH AND C. A. SHELDON, Department of Radiology, Duke University Medical Center, Durham, North Carolina, and Department of Urology, Children’s Hospital Medical Center, Cincinnati, Ohio RadioGraphics, 18: 969-985, 1998 Classification of pediatric scrotal disorders into three typical clinical manifestations-acute scrotal disorders, scrotal masses, and cryptorchidism-provides a practical basis for evaluation with the most
1401
1402
IMAGING
commonly used modalities-sonography, scintigraphy, and magnetic resonance (MR) imaging. Acute scrotal disorders of children include acute epididymitis, torsion of an appendix testis or appendix epididymis, and torsion of the spermatic cord. Either scintigraphy or sonography may be used as the first imaging study, and both can aid in distinguishing among the disorders to different degrees. However, sonography is becoming the preferred modality, primarily because of the superior anatomic detail provided. Scrota1 masses are also best depicted with sonography, although MFi imaging can occasionally be a useful adjunctive modality. In cases of suspected cryptorchidism with equivocal clinical findings, both sonography and MR imaging may be useful, although sonography is usually the initial study. Knowledge of characteristic imaging appearances, as well as benefits and limitations of the available modalities, enables appropriate, expeditious radiologic evaluation of pediatric scrotal disorders.
Editorial Comment: On a monthly basis, RadioGmphics, which is published by the Radiological Society of North America, has excellent imaging review articles mostly culled from the scientific exhibits at their annual meeting. Usually anywhere from 1 to 4 articles are devoted to genitourinary topics and I strongly recommend them. The authors clearly review the multiple imaging modalities that are available for evaluation of the scrotum. They also review the entities that can be readily imaged and diagnosed as common scrotal abnormalities in the pediatric population. Acute scrotal disorders are reviewed including a pediatric case of a scrotal mass. Stanford M. Goldman, M.D.
Cystosonography With Echocontrast: A New Imaging Modality to Detect Vesicoureteric Reflux in Children M. BOSIO,Paediatric Department, Magenta Hospital and Advanced School of Paediatric Ultrasonography, Magenta, Italy Ped. Rad., 25: 250-255, 1998 Abstract Printed in J. Urol., 160 1592, 1998 Editorial Comment: The current gold standard for demonstrating significant reflux is the voiding cystourethrogram. However, this study exposes the child to radiation. Radionuclide cystography exposes the patient to less radiation and reveals significant reflux. However, it fails to show the anatomical abnormality that may underline the reflux, such as urethral valves in the male patient. The authors studied whether ultrasonic techniques using an echo contrast medium could be substituted for the current gold standard and, thus, obviate exposure to radiation. A total of 58 neonates were studied with a galactose suspension. These studies were compared to voiding cystourethrography and radionuclide cystography. It should be noted that not all patients had all 3 studies performed. The reasons for the evaluations included pyelectasis in 21 cases and pyelonephritis in 37. Echo sonography detected 76 refluxing units in 50 patients. Eight patients did not undergo voiding cystourethrography. In 43 patients voiding cystourethrography or radionuclide cystographydetected 62 refluxing units. Thus, the authors believe that echo sonography yields results comparable to voiding cystourethrography. If these excellent results are confirmed by others, one could seriously accept echo sonography as an adequate substitution for radionuclide cystography as the study of choice to following these cases. Although the authors claim that echo sonography did not fail to detect any anatomical variance, such as paraureteral diverticula, ureteroceles and duplication anomalies, I believe that posterior urethral valves can still be missed. Therefore, I would recommend that the initial study still be voiding cystourethrography. Stanford M. Goldman, M.D.
US,CT and MFt Imaging Characteristics of Nephroblastomatosis W. K. ROHRSCHNEIDER, A. WEIRICH, K. RIEDEN, K. DARGE, J. TROGER AND N. GRAF,Departments of Pediatric Radiology and Radiology, University of Heidelberg, Heidelberg, Heidelberg, and Department of Paediatric Oncology, Children’s Hospital, University of HomburglSaar, Hamburg, Germany Ped. Rad., 2 8 435-443, 1998 Objectives. To describe the imaging features of nephroblastomatosis with US, CT and MR, to point out characteristics of differentiation between nephrogenic rests (NR) and Wilms’ tumour (WT) and to determine the most appropriate imaging modality.