UNIT XI

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UNIT XI

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Describing Anatomical Relationships

The description of the anatomical relationships of radiological findings is a problem for radiologists even in their own native tongues. To be able to talk properly on anatomical relationships you have, firstly, to have a sound knowledge of the anatomical structures and, secondly, to know certain anatomical expressions and phrasal verbs usually forgotten long time ago because many years have passed since we studied Anatomy at Medical School.

· Lesions can be medial to the medial collateral ligament, cephalad to the atriocaval junction, caudal to the cecum, lateral to the tail of the pancreas ...

To be cephalad/caudal/lateral to or to be in relation with are some of the indispensable phrasal verbs in Anatomy.

Let us think about this short anatomical paragraph:

· The scaphoid is the largest bone of the first carpal row. It is situated at the superior and external part of the carpus, its direction being from above downwards, outwards, and forwards. Its superior surface is con- vex, smooth, of triangular shape, and articulates with the lower end of the radius.

Anatomical literature is tremendously cumbersome. We, as radiologists, do not need to be so precise with regard to anatomical details, but we do need to be as precise as possible regarding the anatomical relationships of the radiological findings described in our reports.

Let us think now about this short radiological paragraph and notice how many anatomical words and collocations are used:

· Adenoma with ipsilateral stalk movement. There is a microadenoma present on the left side of the gland extending inferiorly and laterally.

This case is unusual in that the stalk is displaced toward the side of the adenoma.

Unit XI Describing a Lesion

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Anatomy and Radiology are intrinsically linked in radiological descriptions since we cannot describe a pituitary gland adenoma without talking about the pituitary gland itself, the stalk, the sella, the carotid arteries, the optic chiasm, the cavernous sinus ...

We can occasionally find difficulties with the spelling of some anatomical structures ± was it gray mater or gray matter, was it dura mater or dura matter? (gray matter and dura mater) ± or with the pronunciation of some terms ± was ªhippoº in hippocampus pronounced as ªhypoº in hypothala- mus? (No) ± but, generally speaking, most radioanatomical difficulties are found in collocations and phrasal verbs such as ªto give offº:

· Previous to its division into the gastroepiploica dextra and the pancrea- ticoduodenalis, the gastroduodenalis artery gives off two or three small inferior pyloric branches to the pyloric end of the stomach and pancreas.

Let us analyze the following two-line sentence of anatomical English ex- tracted without alteration from a musculoskeletal radiology article:

· The elbow is a synovial hinge joint between the trochlea and the capitellum, articulating with the trochlear notch of the ulna and the radial head.

More than half the words of the sentence come from Latin/Greek.

There are:

· One anatomical prepositional verb:

± articulate with

· Three anatomical concepts containing more than one word:

± synovial hinge joint

± trochlear notch

± radial head

· Two Anglo-Saxon anatomical nouns:

± elbow

± joint

· Three Latin/Greek nouns:

± trochlea

± capitellum

± ulna

· Three Latin/Greek adjectives:

± synovial

± trochlear

± radial

Unit XI Describing a Lesion 208

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Imagine an English-speaking lay person in radiology trying to understand the sentence. The result would be something like:

· The elbow is a ... hinge joint between the ... and the ..., articulating with the ... notch of the ... and the ... head.

If you cannot also pronounce properly, what will be understood of your message will be something not too different from:

· The elbow is a ?? hinge joint between the ?? and the ??, articulating with the ?? notch of the ?? and the ?? head.

It is quite obvious that this sentence, without filling in the blanks, has no sense at all.

Although the need for a certain knowledge of Latin/Greek is, in princi- ple, good news for health-care professionals from idiomatically Latin/Greek countries and bad news for those with native tongues that do not come from Latin/Greek, paradoxically many Latin doctors find great difficulty in pronouncing Latin/Greek terms in English, and for them Latin becomes an enemy instead of an ally. It is in the pronunciation of Latin terms where I can identify a colleague of my country as a Spaniard, although he/she speaks otherwise perfect English because it is very difficult to pronounce in English words as usual in our native tongue as edema or lipoma. I have noticed that sometimes Asian doctors, whose native tongues do not come from Latin/Greek, make fewer mistakes pronouncing Latin/Greek terms in English than their colleagues whose native languages have a great deal of Latin/Greek etymology.

· Gross anatomy specimen of the anterior aspect of the elbow joint.

± Gross anatomy refers to macroscopic anatomy as opposed to the terms microscopic and radiological anatomy.

· The lateral aspect of the trochlea.

± Although the lateral trochlea is colloquially acceptable and commonly used, the use of lateral aspect is more appropriate as there is only one trochlea in the elbow.

· The medial aspect of the olecranon

± Similarly, the use of medial aspect is better than medial olecranon as there is only one olecranon in the elbow.

· The capsule is attached to the humeral head

± The phrasal verbis ªto be attached toº. To be attached at is not acceptable.

· The triangular ulnar collateral ligament of the elbow consists of three strong bands.

± To consist of is commonly used in anatomy to describe parts of a certain structure.

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· The posterior band extends from the medial epicondyle to the medial aspect of the olecranon.

± To extend from ... to is one of the most common phrasal verbs in anatomical English.

· The medial epicondyle is the last to fuse.

± Medial epicondyle is a funny term since the prefix ªepiº means above and the ªmedial epicondyleº is above the trochlea so, why don't name it ªepitrochleaº as in some romance languages?

· Pronation and supination take place at the proximal and distal radioulnar joints.

± To pronate and to supinate are typical anatomical verbs (pronation and supination are substantives) that describe upper limb movements.

· The annular ligament is the key structure of the proximal radioulnar joint encircling the radial head and neck without radial attachment.

± Encircling an anatomical structure means to surround it without being attached to it.

· The conjoined insertion of the triceps muscle demonstrates low signal intensity at its attachment to the posterosuperior surface of the olecranon.± Posterosuperior, posteroinferior, posterolateral are preferred to super-

oposterior, inferoposterior, and lateroposterior.

± Anterosuperior, anteroinferior, anterolateral are preferred to superoan- terior, inferoanterior, and lateroanterior.

· The triceps muscle and tendon are located posterior to.

± To be posterior (anterior, lateral, caudal, cephalad, proximal, and distal) to is one of the most common anatomical/radiological phrasal verbs. Posterior (anterior, lateral, caudal, cephalad, proximal, and distal) at is not acceptable.

Common Expressions in Vascular Anatomy

· The pulmonary artery arises from the right ventricle.

· The aorta conveys the oxygenated blood to every part of the body.

· The aorta commences at the upper part of the left ventricle.

· The arch of the aorta extends from the origin of the vessel to the lower border of the body of the third dorsal vertebra.

· The artery describes a curve, the convexity of which is directed upwards and to the right side.

· The ascending part of the aorta is about two inches in length.

· It passes obliquely upwards in the direction of the heart axis.

· The right coronary artery sends a large branch along the thin margin of the right ventricle to the apex.

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· The left coronary artery arises immediately above the free edge of the left semilunar valve.

· The left coronary artery divides into two branches.

· The left coronary artery supplies the left auricle, both ventricles ...

· The innominate artery is the largest branch given off from the arch of the aorta.

· The left common carotid lies on the trachea, esophagus, and thoracic duct.

· The external carotid artery gives off eight branches which may be divided in four sets.

· The lingual artery runs obliquely upwards and inwards to the hyoid bone.

(Anatomical) Relations

· In front

· Behind

· On the right side

· On the left side

· Internally (medially)

· Externally (laterally)

· The ascending part of the arch is covered at its commencement by the trunk of the pulmonary artery and the right auricular appendage, and higher up, is separated from the sternum by the pericardium.

· On the right side, the ascending part of the aorta is in relation with the superior vena cava and right auricle.

Describing Radiological Findings: Word Order

Lesions have shape, borders, density, signal intensity, echogenicity, size, aggressive or non-aggressive aspect, and many other features.

How should we describe lesions, taking into account that we must use many adjectives?

Let us review these radiological descriptions:

· This sagittal image shows an ovoid hyperintense mass directly anterior to the infundibulum.

· A lateral radiograph shows a sclerotic, bubbly lesion in the anterior ti- bial shaft.

· T1-weighted axial images demonstrate a well-circumscribed low signal intensity tumor with intact overlying cortex.

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In most radiological sentences we use fact adjectives (size, length), although sometimes we include opinion adjectives such as ªaggressiveº based on certain radiological features.

As a general rule opinion adjectives go before fact adjectives.

When several fact adjectives coexist in a sentence we put them in the following order:

1. Size/length 2. Shape/width

3. Age (generally not applicable; sometimes used in mentioning a pre- viously described lesion)

4. Color (signal intensity, echogenicity, radiological density ...) 5. Material (bone, muscle, fat ...)

· A 5-cm (1), rounded (2), hyperintense on T2WI (4) fatty (5) lesion was found in the left lobe of the liver.

Describing Focal Lesions

It is far from our intention to offer a comprehensive set of checklists to be followed when reporting in English. Our only, and humble, goal is to pro- vide you with a few useful idiomatic tools that can help you in your first reports in English.

From a radiological point of view these terms are easy and almost every radiologist has known them for many years. But to have them compiled in a couple of pages will save you time and allow you to concentrate on what is really important: the radiological findings themselves.

Since describing focal lesions in a radiological report can be trouble- some for a non-native radiologist because of the scarcity of idiomatic re- sources, to count on an established description pattern is paramount.

These are some aspects you must not forget when describing a focal lesion. This is a standard checklist that can be used for any lesion, although some points are specific depending on the organ in which the lesion is sited:

1. Solitary/single or multiple: If multiple, the pattern of distribution may be reported (diffuse, segmental, lobar ...).

2. Size (large, small): Describe the size in millimeters. If multiple, you may mention the largest one and the smallest one.

3. Shape (round, oval, lobulated, irregular).

4. Contour (smooth, irregular) and delimitation from the adjacent parenchyma (well-delimited/defined, poorly/ill delimited/defined).

5. Location: Describing the location of focal lesions depends on the organ where they are sited.

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· Liver: right hepatic lobe (segments V, VI, VII, VIII), left hepatic lobe (segments II, III, IVA, IVB), Caudate lobe (segment I). Another way of describing where focal lesions are sited is: anterior/posterior aspect of the RHL, LHL, and dome of the liver.

· Pancreas: the location can be divided into head, uncinate process, body and tail of the pancreas.

· Kidney: we refer to upper, mid or lower portions of the kidney. Upper pole or lower pole can also be used. The use of mid-pole is somewhat contradictory since poles mean extremes, but nonetheless ªmid-poleº is extensively used.

· Lung: in the lung we locate the lesion according to the lobe (RUL, RLL, ML, LUL, LLL) and sometimes to the segment (the segments can be designated either anatomically or by numbers. There are two classical numerical classifications, the radiological and that of thoracic surgeons which basically differ in upper lobe segments 2 and 3). A few small details must be borne in mind when reporting lung lesions:

± Don't forget that the expression right middle lobe is redundant since there is no left middle lobe since the lingula belongs to the left upper lobe.

± Don't forget that segments IV and V belong to the middle lobe in the right lung and the lingula to the left lobe, but segment IV is be- side segment V in the middle lobe and above segment V in the lingula.

± Don't forget that segment VII (anterior, medial, and basal) does not exist as such in the left lung (some authors talk about segment VII±VIII).

· CNS: intracranial lesions can be either intraaxial or extraaxial. In- traaxial: cerebrum (frontal, temporal, parietal, and occipital lobes, and corpus callosum), brain stem, and cerebellum. Extraaxial: dura mater, arachnoid, or pia mater.

· Spine lesions can be divided into intradural intramedullary, intradural extramedullary and extradural.

6. Density:

· Homogeneous/heterogeneous

· Low/high density/intensity

· Cystic/solid/complex (US)

· Search for the presence of other different densities within the lesion:

calcifications, fat, blood, necrosis, capsule, septa, scar.

7. Enhancement (enhancing lesion, non-enhancing lesion) and pattern of enhancement:

· Evaluation in:

± Arterial phase/portal venous phase/equilibrium phase/delayed phase (liver).

± Arterial phase/corticomedullary phase/nephrographic phase/excre- tory phase (kidney). Plus, delayed phase if bladder needs to be evaluated.

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± Arterial phase/portal venous phase (rest of abdomen).

± Arterial phase/venous phase (brain).

· Describing the enhancement:

± Early enhancement vs. delayed enhancement

± Diffuse homogeneous vs diffuse heterogeneous

± Peripheral vs. central

± Peripheral nodular vs. peripheral rim-like

± Centripetal filling

± Enhancing capsule/enhancing scar/enhancing septa

± Enhancing satellite nodules

± Early/delayed wash-out 8. Relations:

· Extension:

± Superiorly, inferiorly, laterally, medially, anteriorly, posteriorly

· Displacement of adjacent structures:

± Superiorly, inferiorly, medially, laterally, anteriorly, posteriorly

· Invasion, compression or encasement of adjacent structures

± Arteries, veins, biliary tree and gallbladder, pelvocaliceal system, brain stem ...

9. Specific findings to look for:

· Liver: Search for: portal vein thrombosis, biliary tree dilation, gallbladder invasion, invasion of adjacent parenchyma, capsular retrac- tion, hilar adenopathy, satellite lesions

· Pancreas: Search for: splenic vein thrombosis, Wirsung dilatation, distal common bile duct dilatation, peripancreatic/retroperitoneal adenopathy

· Kidney: Search for: renal vein thrombosis, pelvocaliceal distortion/dilation, ureteral dilatation, hilar and retroperitoneal adenopathy, peri- renal fat involvement

· Brain: Search for: midline shift, ventricular dilatation/compression, brain stem displacement, cerebral herniation, hemorrhage, arterial encasement and secondary infarction, extraaxial lesions

· Lung: Search for: atelectasis, distal consolidation (pneumonitis), hilar and mediastinal adenopathy, hilar or mediastinal direct invasion, pleural effusion, chest wall invasion, pericardial invasion

· Bone: Search for: cortical destruction, cortical expansion, periosteal reaction, soft tissue mass, encasement/infiltration of neurovascular bundles