Thiel, David D.

This is the first report, to our knowledge, of widespread, histologically confirmed trisacryl gelatin pulmonary microembolism after renal artery embolization (RAE). In addition, this is the first report of lung involvement by both metastatic renal cell carcinoma (RCC) and an embolic agent used for RAE. The patient was a 63-year-old woman who recently presented with both dyspnea on exertion and productive cough. Her past medical history included clear cell RCC, which was treated with preoperative trisacryl gelatin microsphere RAE and right nephrectomy 9 years earlier. Computed tomography of the chest showed multiple lung nodules, a mass-like density in the left lower lobe, and mediastinal and hilar lymphadenopathy. Wedge resections of the lung showed multiple foci of metastatic RCC and extensive involvement of the muscular pulmonary arteries by trisacryl gelatin microspheres.

Purpose: Dual-energy computed tomography (DECT) is an emerging imaging modality with the unique capability of determining urinary stone composition. This study compares radiation exposure of DECT, standard single-energy CT (SECT), and low-dose renal stone protocol single-energy CT (LDSECT) for the evaluation of nephrolithiasis in a single in vivo patient cohort. Materials and Methods: Following institutional review board (IRB) approval, we retrospectively reviewed 200 consecutive DECT examinations performed on patients with suspected urolithiasis over a 6-month period. Of these, 35 patients had undergone examination with our LDSECT protocol, and 30 patients had undergone examination of the abdomen and pelvis with our SECT imaging protocol within 2 years of the DECT examination. The CT dose index volume (CTDI vol ) was used to compare radiation exposure between scans. Image quality was objectively evaluated by comparing image noise. Statistical evaluation was performed using a Student's t -test. Results: DECT performed at 80/140 kVp and 100/140 kVp did not produce a significant difference in radiation exposure compared with LDSECT ( p =0.09 and 0.18, respectively). DECT performed at 80/140 kVp and 100/140 kVp produced an average 40% and 31%, respectively, reduction in radiation exposure compared with SECT ( p <0.001). For patients imaged with the 100/140 kVp protocol, average values for images noise were higher in the LDSECT images compared with DECT images ( p <0.001) and there was no significant difference in image noise between DECT and SECT images in the same patient ( p =0.88). Patients imaged with the 80/140 kVp protocol had equivocal image noise compared with LDSECT images ( p =0.44), however, DECT images had greater noise compared with SECT images in the same patient ( p <0.001). Of the 75 patients included in the study, stone material was available for 16; DECT analysis correctly predicted stone composition in 15/16 patients (93%). Conclusion: DECT provides knowledge of stone composition in addition to the anatomic information provided by LDSECT/SECT without increasing patient radiation exposure and with minimal impact on image noise.

The use of dual-energy computed tomography (DECT) for evaluating urinary calculi has been appreciated due to the modality’s capability of differentiating between uric acid (UA) and non-UA stones, which are color coded based on a postprocessing algorithm. No other imaging modality or laboratory test is able to identify the stone composition without first attaining the stone material. Knowledge of the stone composition is clinically significant since UA calculi may be treated medically whereas non-UA calculi may require surgical removal. Regardless of the stone type, ureteral stents are often placed to prevent or treat obstruction. Recent work has demonstrated that commonly used stents are also colored based on their dual energy characteristics and may thereby either improve or obscure the identification of adjacent calculi. Herein, we report the case of a 65-year-old man who underwent percutaneous nephrolithotomy of a large staghorn stone with subsequent significant residual stone fragments noted on a follow-up scan. By using three-dimensional DECT and taking advantage of color contrasting, the stone composition, burden, shape, and boundary were clearly depicted apart from the adjacent stent, resulting in successful medical treatment and obviating the need for further surgical intervention.

Prostatic stromal hyperplasia with atypia (PSHA) is a rare histologic finding diagnosed incidentally on prostate biopsies, transurethral resection specimens, and radical prostatectomy specimens. PSHA has a bizarre histologic appearance and these lesions often raise concern for sarcoma; however, their clinical course is indolent and does not include extraprostatic progression. We discuss a case of PHSA discovered on prostate biopsy performed for an abnormal digital rectal examination and review the literature on this rare pathologic finding.