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DOI: 10.1148/radiol.2441040790
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(Radiology 2007;244:303-308.)
© RSNA, 2007

Diagnosis Please

Case 116: Lymphangioleiomyomatosis1

Anil K. Attili, FRCR and Ella A. Kazerooni, MD, MS

1 From the Department of Thoracic Radiology, University of Michigan Health System, 1500 E Medical Center Dr, Taubman/B-1/132, Box 0302, Ann Arbor, MI 48109. Received May 10, 2004; revision requested July 21; revision received October 25; final version accepted December 14.

Correspondence: Address correspondence to A.K.A. (e-mail: aattili{at}umich.edu).


   HISTORY
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 HISTORY
IMAGING FINDINGS
 DISCUSSION
 References
 
A 49-year-old premenopausal woman presented with acute onset of lower abdominal pain. Physical examination revealed her abdomen was distended and nontender. Her white blood cell count and serum markers for ovarian cancer were normal ({alpha}-fetoprotein level, 1.6 µg/L; Ca-125 level, 15 U/mL; ß-human chorionic gonadotrophin level < 2 IU/mL). She had no important medical history; in particular, she had no history of malignancy. She denied having any chest symptoms; in particular, she denied experiencing chest pain, cough, or dyspnea. She had stopped smoking at the age of 40 years after having smoked for a total of 20 pack-years.

A computed tomographic (CT) examination of the abdomen and pelvis was performed. Helical CT was performed with 150 mL of intravenous contrast material (iohexol, Omnipaque; Amersham Healthcare, Cork, Ireland) and 750 mL of oral contrast material (diatrizoate sodium, Hypaque; Amersham Health, Princeton, NJ). CT sections were 5 mm thick and were acquired from the top of the diaphragm through the ischial tuberosities with a rotation time of 13.5 seconds per rotation and use of a LightSpeed 16 CT scanner (GE Medical Systems, Milwaukee, Wis).


   IMAGING FINDINGS
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 HISTORY
 IMAGING FINDINGS
DISCUSSION
 References
 
Contrast material–enhanced CT revealed large encapsulated low-attenuation retroperitoneal cystic masses in the abdomen and pelvis (Fig 1c–1f). Fat-fluid levels were present in some cysts. Separate smaller paraaortic cystic lymph nodes (Fig 1c) were also found. The kidneys, liver, spleen, and adrenal glands were normal. Images through the lower thorax revealed bilateral small pleural effusions (Fig 1a) and small thin-walled cystic lung parenchymal lesions (Fig 1b).


Figure 1A
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  		Figure 1a: (a) Transverse CT image through the lung bases with soft-tissue window settings demonstrates small bilateral pleural effusions (arrows). (b) Transverse CT image through the lung bases with lung window settings shows thin-walled lung parenchymal cysts (arrow). (c) Transverse CT image of the abdomen through the level of the renal hila shows cystic retroperitoneal masses (lymphangioleiomyomas) (thin arrows) and separate smaller cystic lymph nodes (thick arrow). (d) Transverse CT image through the lower abdomen shows cystic retroperitoneal masses (lymphangioleiomyomas) and a fat-fluid level (arrow). (e, f) Transverse CT images of the pelvis show lymphangioleiomyomas (arrow) extending into the pelvis.

 

Figure 1B
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  		Figure 1b: (a) Transverse CT image through the lung bases with soft-tissue window settings demonstrates small bilateral pleural effusions (arrows). (b) Transverse CT image through the lung bases with lung window settings shows thin-walled lung parenchymal cysts (arrow). (c) Transverse CT image of the abdomen through the level of the renal hila shows cystic retroperitoneal masses (lymphangioleiomyomas) (thin arrows) and separate smaller cystic lymph nodes (thick arrow). (d) Transverse CT image through the lower abdomen shows cystic retroperitoneal masses (lymphangioleiomyomas) and a fat-fluid level (arrow). (e, f) Transverse CT images of the pelvis show lymphangioleiomyomas (arrow) extending into the pelvis.

 

Figure 1C
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  		Figure 1c: (a) Transverse CT image through the lung bases with soft-tissue window settings demonstrates small bilateral pleural effusions (arrows). (b) Transverse CT image through the lung bases with lung window settings shows thin-walled lung parenchymal cysts (arrow). (c) Transverse CT image of the abdomen through the level of the renal hila shows cystic retroperitoneal masses (lymphangioleiomyomas) (thin arrows) and separate smaller cystic lymph nodes (thick arrow). (d) Transverse CT image through the lower abdomen shows cystic retroperitoneal masses (lymphangioleiomyomas) and a fat-fluid level (arrow). (e, f) Transverse CT images of the pelvis show lymphangioleiomyomas (arrow) extending into the pelvis.

 

Figure 1D
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  		Figure 1d: (a) Transverse CT image through the lung bases with soft-tissue window settings demonstrates small bilateral pleural effusions (arrows). (b) Transverse CT image through the lung bases with lung window settings shows thin-walled lung parenchymal cysts (arrow). (c) Transverse CT image of the abdomen through the level of the renal hila shows cystic retroperitoneal masses (lymphangioleiomyomas) (thin arrows) and separate smaller cystic lymph nodes (thick arrow). (d) Transverse CT image through the lower abdomen shows cystic retroperitoneal masses (lymphangioleiomyomas) and a fat-fluid level (arrow). (e, f) Transverse CT images of the pelvis show lymphangioleiomyomas (arrow) extending into the pelvis.

 

Figure 1E
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  		Figure 1e: (a) Transverse CT image through the lung bases with soft-tissue window settings demonstrates small bilateral pleural effusions (arrows). (b) Transverse CT image through the lung bases with lung window settings shows thin-walled lung parenchymal cysts (arrow). (c) Transverse CT image of the abdomen through the level of the renal hila shows cystic retroperitoneal masses (lymphangioleiomyomas) (thin arrows) and separate smaller cystic lymph nodes (thick arrow). (d) Transverse CT image through the lower abdomen shows cystic retroperitoneal masses (lymphangioleiomyomas) and a fat-fluid level (arrow). (e, f) Transverse CT images of the pelvis show lymphangioleiomyomas (arrow) extending into the pelvis.

 

Figure 1F
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  		Figure 1f: (a) Transverse CT image through the lung bases with soft-tissue window settings demonstrates small bilateral pleural effusions (arrows). (b) Transverse CT image through the lung bases with lung window settings shows thin-walled lung parenchymal cysts (arrow). (c) Transverse CT image of the abdomen through the level of the renal hila shows cystic retroperitoneal masses (lymphangioleiomyomas) (thin arrows) and separate smaller cystic lymph nodes (thick arrow). (d) Transverse CT image through the lower abdomen shows cystic retroperitoneal masses (lymphangioleiomyomas) and a fat-fluid level (arrow). (e, f) Transverse CT images of the pelvis show lymphangioleiomyomas (arrow) extending into the pelvis.

 

   DISCUSSION
TOP
 HISTORY
 IMAGING FINDINGS
 DISCUSSION
References
 
Given the constellation of findings—including low-attenuation retroperitoneal cystic masses (lymphangioleiomyomas) with fat-fluid levels, enlarged low-attenuation abdominal lymph nodes together with thin-walled lung parenchymal cysts, and small bilateral pleural effusions in a premenopausal woman—the most likely diagnosis was lymphangioleiomyomatosis (LAM). High-spatial-resolution CT scanning enabled us to confirm the presence of diffuse, thin-walled cystic lung parenchymal lesions with intervening normal parenchyma (Fig 2). Ultrasonography-guided 18-gauge core biopsy and fine-needle aspiration biopsy (cloudy red fluid was aspirated) of the complex cystic right retroperitoneal mass were performed. Pathologic analysis enabled us to confirm the diagnosis of lymphangiomyoma, and tissue staining was positive for actin, desmin, and the HMB-45 antibody.


Figure 2
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  		Figure 2: Transverse high-spatial-resolution CT image demonstrates thin-walled lung parenchymal cysts (arrow indicates one of many) with intervening normal parenchyma.

 
LAM is a rare idiopathic disorder found almost exclusively in premenopausal women, and it is characterized by the proliferation of abnormal smooth muscle cells (LAM cells) in the pulmonary interstitium and along the thoracic and abdominal lymphatics (1–5). LAM cells characteristically stain positive for vimentin, desmin, {alpha}-smooth muscle actin, and the monoclonal antibody HMB-45 (6–8).

Patients with LAM most commonly have dyspnea, pneumothorax, and cough at presentation. Chest pain, chylous pleural effusions, hemoptysis, and wheezing are less common at presentation but may develop during the course of the disease (1,3,9–11). Extrapulmonary features include renal angiomyolipomas, lymph node masses, cystic soft-tissue masses (lymphangiomyomas), chylous ascites, and uterine fibroids (leiomyomas) (1,12–17). In a large series of 80 patients with pulmonary LAM, 76% had positive abdominal findings at imaging: These findings included renal angiomyolipoma (54%), enlarged abdominal lymph nodes (39%), and lymphangiomyomas (16%) (16). Less commonly, ascites (10%) and hepatic angiomyolipoma (4%) were present. Initial manifestation of LAM with abdominal pain is a recognized, albeit uncommon, finding (18–20). Other manifestations of extrapulmonary LAM include palpable abdominal masses and ascites (21,22). If the diagnosis of extrapulmonary LAM precedes the diagnosis of pulmonary LAM, the patient usually develops thoracic symptoms within 1–2 years (21).

Lymphangioleiomyomas result from the proliferation of smooth muscle cells in the lymphatic vessels, causing obstruction and dilation of the lymphatic vessels and resulting in cystic collections of chylous material (4,12,23–25). At CT, dilated retroperitoneal lymph vessels may have thick or thin walls and may contain low-attenuation (3–25 HU) material (16). Lymphangioleiomyomas may lie between and displace vascular structures in the retroperitoneum. Overdistention of lymph cysts may result in rupture and chylous ascites (22).

Radiologic diagnosis is difficult when LAM involves only the retroperitoneum or when it involves the retroperitoneum before it involves the lungs. Cystic lymphangiomas are similar to lymphangioleiomyomas in patients with LAM; however, the former consists of endothelium-lined lymphatic spaces, without the muscle or LAM cells in the walls that are diagnostic of lymphangioleiomyoma. When enlarged lymph nodes are seen in conjunction with lymphangioleiomyomas, a neoplastic process—such as lymphoma, metastasis, or primary cystic retroperitoneal tumor—may be misdiagnosed. Liposarcomas, leiomyosarcomas, and fibrosarcomas with cystic degeneration can be identified because they usually have solid components. Old hematomas, abscesses, urinomas, and lymphoceles must also be considered in the differential diagnosis of a lymphangioleiomyoma. A fat-fluid level in a retroperitoneal cystic mass is a recognized feature of a mature teratoma (26).

Pulmonary cysts have been present in nearly all cases of LAM reported to date. The mechanism of cyst formation in patients with LAM is controversial; both small airway obstruction and proteolytic destruction with amalgamation of alveoli have been proposed as possible mechanisms (27). High-spatial-resolution CT is both sensitive and specific in the diagnosis of pulmonary LAM, depicting characteristic round thin-walled cysts uniformly distributed throughout the lungs (28,29). The profusion of cysts and the quantitative CT scores correlate with impairment at pulmonary function testing and clinical condition (28,30). Langerhans cell histiocytosis can result in similar thin-walled cysts; however, the preferential distribution in the upper lungs and the presence of associated nodules in patients with Langerhans cell histiocytosis should help differentiate the entities (31).

While the clinical and radiologic features of LAM are characteristic, a definitive diagnosis is usually established with tissue biopsy, as the only medical therapy of benefit (hormonal therapy with medroxyprogesterone) will induce early menopause in these women, who are typically of child-bearing age. In most cases, a biopsy specimen is surgically removed from the lung. Reports suggest that transbronchial lung biopsy specimens (32) and pleural fluid cytologic analysis may be sufficient for diagnosis in certain cases (33). Since LAM can involve extrapulmonary sites, such as lymph nodes and abdominal or pelvic masses, a definitive diagnosis can occasionally be made with biopsy specimens obtained from such sites (19,21,34).

Some authors believe LAM represents a partial manifestation of tuberous sclerosis, as both abnormalities manifest with the same pulmonary lesions and may involve concomitant angiomyolipomas of the kidneys (35–37). Pulmonary LAM can occur as part of the tuberous sclerosis complex, and patients with pulmonary manifestations of this complex may not have the classic features, such as epilepsy and mental retardation (36). Generally, tuberous sclerosis is diagnosed clinically. Criteria for diagnosis have been described by the National Tuberous Sclerosis Association (38). All women with LAM should undergo a careful family history review and clinical examination for stigmata of tuberous sclerosis complex and should be seen by a clinical geneticist in cases of doubt (11). There were no criteria to satisfy the diagnosis of tuberous sclerosis in this patient.

Among the manifestations of LAM, pulmonary involvement is responsible for most of the morbidity and mortality. The disease is slowly progressive, leading to respiratory failure and death (1). Diverse treatments—including oophorectomy, tamoxifen, luteinizing hormone releasing hormone analogue, and progesterone—as well as combinations of these treatments have been tried. Among these, early administration of medroxyprogesterone is currently the most accepted medical treatment (2,3,11,39–42). When the patient's functional status declines, lung transplantation is the best therapeutic option. Lung transplantation, mainly of one lung, has been performed successfully in patients with end-stage LAM. Early and late survival rates after lung transplantation are comparable in patients with LAM versus in patients with other diseases (14,43). Morbidity is common after lung transplantation in patients with LAM and is usually due to LAM-related complications, including extensive pleural adhesions leading to excessive intraoperative hemorrhage, native lung pneumothorax, chylous effusions, chylous ascites, complications from renal angiomyolipomas, and recurrent LAM in the allograft (14,43,44).


   FOOTNOTES
 
Authors stated no financial relationship to disclose.


Part one of this case appeared 4 months previously and may contain larger images.

 


   References
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 HISTORY
 IMAGING FINDINGS
 DISCUSSION
 References
 

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Congratulations to the 176 individuals and nine resident groups that submitted the most likely diagnosis (lymphangioleiomyomatosis) for Diagnosis Please, Case 116. The names and locations of the individuals and resident groups, as submitted, are as follows:

Individual responses

Paulo Gil Agostinho, MD, Coimbra, Portugal
Erhan Akpinar, Ankara, Turkey
Skip Michael Alderson, MD, Abington, Pa
Albert J. Alter, MD, Madison, Wis
Roger L. Antonelli, MD, Dayton, Ohio
Alexandra Araújo, Lisbon, Portugal
Jason Brandon Ashley, MD, London, Ontario, Canada
Monica Ballesta Moratalla, MD, Valencia, Spain
Ronald L. Becker, MD, Rolling Hills, Calif
Richard John Beedie, MBChB, Auckland, New Zealand
Nitthida Billateh, MD, Hat-Yai, Songkhla, Thailand
Gustav A. Blomquist, MD, Houston, Tex
J. Scott Bolton, MD, Dothan, Ala
Douglas Charles Brown, MD, Virginia Beach, Va
Michael Patrick Buetow, MD, Okemos, Mich
Marcelo Cabrini, Lomas de Zamora, Argentina
Antonio Albuquerque Cavalcanti, MD, São Paulo, Brazil
Marcos Nogueira Chagas, MD, Brasilia, Brazil
Natesan Chidambaranathan, MD, Chennai, India
Michael Harold Childress, MD, Silver Spring, Md
Haris Chrysikopoulos, Corfu, Greece
Alex T. Chuang, MD, Dallas, Tex
Ming-Tsung Chuang, MD, Kaohsiung, Taiwan
Enrico Citarella, Vicenza, Italy
Jay M. Colby, MD, Pawcatuck, Conn
Neal Raymond Conti, MD, Seattle, Wash
Gonzalo Lecumberri Cortes, MD, Bilbao, Vizcaya, Spain
Alberto Cunat, MD, Valencia, Spain
John Curtis, Liverpool, United Kingdom
Marc G. De Baets, MD, Agra, Switzerland
Peter De Baets, Damme, Belgium
Andrew Robert Deibler, MD, Winston-Salem, NC
Mustafa Kemal Demir, MD, Istanbul, Turkey
Thaworn Dendumrongsup, MD, Songkla, Thailand
Bart D'herde, Hasselt, Belgium
Susana Dias, MD, Porto, Portugal
Seyed A. Emamian, MD, PhD, Rockville, Md
Enrique Remartinez Escobar, MD, Melilla, Spain
Virginia Fattal Jaef, MD, Rosario, Argentina
Brett D. Ferdinand, MD, Livingston, NJ
James Bernard Fitzgerald, MD, Orchard Park, NY
Angeles Franco Lopez, Madrid, Spain
Akira Fujikawa, MD, Setagaya, Tokyo, Japan
Ann S. Fulcher, MD, Midlothian, Va
Rajneesh Galwa, Jaipur, India
Ram Prakash Galwa, MD, Chandigarh, India
Douglas Joseph Gardner, MD, Windsor, Ontario, Canada
William George Gawman, MD, Waterloo, Ontario, Canada
Hakan Genchellac, MD, Istanbul, Turkey
Gilles Genin, Annecy, France
Vidisha V. Ghole, MD, Irving, Tex
Francisco Jose Gonzalez, Santander, Spain
Navraj S. Grewal, MD, Elmhurst, Ill
Aleksandar Grgic, MD, Zweibruecken, Germany
Dan G. Gridley, MD, Phoenix, Ariz
Terrence M. Gross, MD, Winter Park, Fla
Ashish Gupta, MD, Chandigarh, India
Pramod Kumar Gupta, MD, Plano, Tex
Leticia Gutierrez, MD, Madrid, Spain
Ferris M. Hall, MD, Brookline, Mass
Srinivasan Harish, MBBS, Burlington, Ontario, Canada
Howard J. Harvin, MD, Scottsdale, Ariz
Marc Heinrich, Erlangen, Germany
Mark David Hohenwalter, MD, Milwaukee, Wis
Alberto Carlucci Iaia, MD, Wilmington, Del
Nasir M. Jaffer, MD, Toronto, Ontario, Canada
Rathachai Kaewlai, MD, Boston, Mass
Pinar S. Karakas, MD, Cleveland, Ohio
Amna Abdulkarim Kashgari, MD, Riaydh, Saudi Arabia
Masako Kataoka, MD, Cambridge, United Kingdom
Katsuhiko Kato, MD, Nagoya, Aichi, Japan
Ashok Katti, MD, Warrington, Cheshire, United Kingdom
Nantaka Kiranantawat, MD, Songkla, Thailand
Arnold Jay Klein, MD, Portland, Ore
Steven A. Klein, MD, Shrewsbury, Mass
Richard Eric Krauthamer, MD, Rolling Hills, Calif
Alexis Lacout, MD, Paris, France
Mario A. Laguna, MD, Milwaukee, Wis
Matias Landi, MD, Mar del Plata, Argentina
Martin Lecompte, MD, Manotick, Ontario, Canada
Karl Juergen Lehmann MD, Karlsruhe, Germany
John Taek Lim, MD, Newport Coast, Calif
David Anthony Lisle, MBBS, Brisbane, Australia
Alexander Patrick LoRusso, MD, Santa Fe, NM
Patricia Ann Lowry, MD, Chattanooga, Tenn
Edward Lubat, MD, Englewood, NJ
George D. Lyons, MD, Tulsa, Okla
Naganathan B.S. Mani, MD, Nassau, Bahamas
Satoshi Matsushima, MD, Tokyo, Japan
Waldir Heringer Maymone, MD, Rio de Janeiro, Brazil
Frank J. McKowne, MD, Vancouver, Wash
Koen Pieter Mermuys, MD, Heverlee, Belgium
Michael Philip Meyers, MD, Winnipeg, Manitoba, Canada
Nikolaos Michailidis, Thessaloniki, Greece
Steven J. Michel, MD, Bellingham, Wash
Steven Frank Millward, MBChB, Omemee, Ontario, Canada
Manabu Minami, MD, Yokohama, Kanagawa, Japan
Jose Mondello, MD, Buenos Aires, Argentina
Douglas J. Moote, MD, Hartford, Conn
Gregg Emil Moral, MD, Cedarburg, Wis
Thomas Moser, MD, Strasbourg, France
Utaroh Motosugi, MD, Yamanashi, Japan
Kazuyoshi Nakamura, MD, Yokkaichi, Japan
Tammam Naim Nehme, MD, East Wenatchee, Wash
Soheil Niku, MD, San Diego, Calif
Mizuki Nishino, MD, Boston, Mass
Albert Nizzero, MD, Sudbury, Ontario, Canada
Hiroshi Nobusawa, MD, PhD, Ota, Tokyo, Japan
Kuni Ohtomo, MD, Tokyo, Japan
Patrick Augustine O'Keeffe, MBBCh, Clonmel, Ireland
Sanford M. Ornstein, MD, Paradise Valley, Ariz
Klaus Orth, Aachen, Germany
Marc Gideon Ossip, MD, Toronto, Ontario, Canada
Carlos Ovejero Vela, Barcelona, Spain
Ann Burleson Owen, MD, Murfreesboro, Tenn
Neeraj Jitendra Panchal, MD, San Diego, Calif
David M. Panicek, MD, New York, NY
Narendrakumar P. Patel, MD, Newburgh, NY
Suresh K. Patel, MD, Chicago, Ill
Yeliz Pekcevik, Izmir, Turkey
Juan Carlos Pernas, Barcelona, Spain
Oscar Persiva Morenza, MPH, Barcelona, Spain
Carlo Lucius E. Petralli, MD, Bruderholz, Switzerland
Stacey L. Piche, MD, Summerland, British Columbia, Canada
Ivan Pilate, Brussels, Belgium
Fernando Antonio Pires, MD, Porto, Portugal
Nirmalkumar Prabhu, Trivandrum, Kerala, India
Ilias Primetis, MD, Athens, Greece
Shawn Paul Quillin, MD, Charlotte, NC
Claudio Prata Ramos, MD, Juiz de Fora, Brazil
Daniel C. Rappaport, MD, Toronto, Ontario, Canada
Matthew C. Rheinboldt, MD, Nashville, Tenn
Manoel De Souza Rocha, MD, São Paulo, Brazil
Tsutomu Sakamoto, MD, Tokyo, Japan
Hatice Tuba Sanal, MD, Ankara, Turkey
Roberto Queiroz dos Santos, MD, Rio de Janeiro, Brazil
Debra Marion Sarasohn, MD, New York, NY
Steven Mark Schultz, MD, Fort Worth, Tex
Anthony J. Scuderi, MD, Johnstown, Pa
Hidekazu Seo MD, Hamamatsu, Shizuoka, Japan
Matthew P. Shapiro, MD, Charlottesville, Va
Hideki Shima, MD, Tokyo, Japan
Taro Shimono, MD, Osaka, Sayama, Japan
Grady V. Shue, Jr, MD, Hickory, NC
Darrin S. Smith, MD, Visalia, Calif,
Annemie Snoeckx, MD, Zandhoven, Belgium
David F. Sobel, MD, La Jolla, Calif
James D. Sprinkle, Jr, MD, Spotsylvania, Va
Daniela Stoisa, Rosario, Argentina
Subramanian Subramanian, MD, New Delhi, India
Kouichi Sugiyama, Numazu, Japan
Venkateswar Rao Surabhi, MBBS, San Antonio, Tex
Norio Takahashi, MD, Fukui, Japan
Ken Tamai, Kyoto, Japan
Ayako Tamura MD, Tokyo, Japan
Douglas L. Teich, MD, Brookline, Mass
Osman Temizoz, Edirne, Turkey
Kazuma Terauchi, Fujieda City, Japan
Eugene Tong, MD, Austin, Tex
Ozgur Tosun, Ankara, Turkey
Eugene Walter Tryciecky, DO, Farmington Hills, Mich
Baris Ismail Turkbey, MD, Ankara, Turkey
Unni K. Udayasankar, MD, FRCR, Atlanta, Ga
Hiroyuki Ueda, MD, Kobe, Japan
Eleni Vafeiadou, Thessaloniki, Greece
Filiep K.B. Van Geluwe, MD, Boutersem, Belgium
Rick Robert Van Rijn, MD, PhD, Capelle aan den IJssel, the Netherlands
Nanda Venkatanarasimha, MBBS, MRCP, Plymouth, United Kingdom
Ricardo Luis Videla, Córdoba, Argentina
Christopher P. Vittore, MD, Belvidere, Ill
Ivan Vollmer, MD, Barcelona, Spain
Mary G. Wang, MD, San Jose, Calif
David Craig Wilkes, MD, Dallas, Tex
Stanko Yovichevich, MD, Sydney, Australia
Joe Yut, Olathe, Kan
Dahua Zhou, MD, East Meadow, NY

Resident group responses

Baylor University Medical Center Radiology Residents, Dallas, Tex
Diagnostico Medico Radiology Residents, Buenos Aires, Argentina
Hospital Italiano Cordoba Radiology Residents, Cordoba, Argentina
Kaohsiung Medical University Radiology Residents, Kaohsiung, Taiwan
Prince of Songkla University Radiology Radiology Residents, Hat Yai, Songkla, Thailand
Santa Casa da Misericórdia do Rio de Janeiro Radiology Residents, Rio de Janeiro, Brazil
Trakya University School of Medicine Radiology Residents, Edirne, Turkey
University of Pennsylvania Radiology Residents, Philadelphia, Pa
Virginia Commonwealth University Radiology Residents, Richmond, Va





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