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Purpose: Investigate the intermediate-term oncological outcome after negative multiparametric MRI (mpMRI) of the prostate in patients without biopsy proven prostate cancer (PCa)., Methods: The retrospective study included 121 patients with negative mpMRI (Prostate Imaging Reporting and Data System version 2.1 category<3) performed at our institution between 2012 and 2017 without known biopsy proven PCa. Clinical and pathological data were collated including post-MRI prostatic tissue diagnoses with highest Grade Group and most recent prostate specific antigen (PSA) levels up to any definitive prostate cancer treatment. Mean PSA velocities between patients with and without a subsequent diagnosis of Grade Group 2 or higher (GG2+) PCa were compared, and an optimal threshold value was calculated., Results: Outcome data available included PSA values in 117 patients and prostate tissue sampling in 52 patients. Over a median follow up interval of 49.8 months, only 11 of 121 patients (9.1%) were diagnosed with GG2+ PCa, 10 patients (8.3%) with GG1 PCa, and 31 patients (25.6%) had negative prostate tissue samples. Mean PSA velocity was significantly higher in the patients diagnosed with GG2+ PCa (3.87 ng/mL/year) compared to those not diagnosed with GG2+ PCa (-0.71 ng/mL/year, p < 0.001). A threshold PSA velocity of 0.27 ng/mL/year had a 100% sensitivity and 69.8% specificity for GG2+ PCa (AUC: 0.898)., Conclusion: <10% of patients with negative mpMRI without prior biopsy proven PCa were diagnosed with GG2+ PCa over median follow up of over four years and were associated with PSA velocity of ≥0.27 ng/mL/year. PSA monitoring may be a reasonable management strategy in patients with a negative mpMRI without biopsy proven PCa., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Despite advances in diagnosis and treatment, prostate cancer remains the second leading cause of cancer related mortality in men. Prognosis is variable and dependent on several clinical and genetic factors, including BRCA gene mutations. Recent clinical studies have reported that BRCA-associated prostate cancer is a more aggressive subtype with a higher probability of nodal involvement and distant metastases at the time of diagnosis, but radiological findings have not been described. Accurate recognition of those tumors could help guide clinical management and prompt testing and counseling for BRCA mutations. We have recently encountered four patients with BRCA-associated prostate cancer who underwent multiparametric MRI. The MRI appearances of these tumors, which were generally locally advanced and aggressive in appearance, are presented to facilitate recognition of BRCA-associated prostate cancer and guide potential genetic testing and counseling., (Copyright © 2022 Elsevier Inc. All rights reserved.)

MRI features are presented in a multicenter retrospective series of five patients with a unilateral masslike lesion seen in the genitourinary diaphragm at MRI performed for known or suspected prostate cancer. In all cases, the lesion appeared as an encapsulated 1.3 to 3.0 cm mass of heterogeneous low or intermediate T2 signal intensity in the genitourinary diaphragm, and targeted biopsy demonstrated benign Cowper's gland tissue. This entity is a potential imaging pitfall that could result in a diagnosis of an exophytic nodule of benign prostatic hyperplasia or local spread of prostate cancer. We present these cases to facilitate correct identification of Cowper's gland hyperplasia as an occasional finding at MRI of the prostate., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To retrospectively study the performance of CT-guided biopsy of target prostate lesions at a single institution., Methods: Between May 2016 and February 2021, we retrospectively identified all men without rectal access who underwent transgluteal CT-guided biopsy of PIRADS 4 or 5 targets detected on multiparametric MRI (n = 9). Clinical, radiological, and pathological details were collected by review of the electronic medical record, and included age, pre-biopsy prostate specific antigen (PSA) value, prior biopsy history, biopsy targeting technique and procedural details, complications, and final histologic diagnosis. Two targeting techniques were used: Localizing with anatomic landmarks or localizing with contrast enhancement., Results: Mean patient age was 69 years (range, 49-74) and mean PSA was 14.6 ng/mL (range 7-23). Four lesions were targeted using anatomic landmarks and 5 were targeted using contrast enhancement. All biopsies were technically successful and all resulted as prostate cancer. Three biopsies showed Gleason 6 cancer and 6 biopsies showed clinically significant prostate cancers with Gleason 7 or above. There were no major complications. 7 patients went on to definitive treatment with surgery or radiation., Conclusion: Transgluteal CT-guided biopsy of MRI detected prostate lesions diagnoses clinically significant prostate cancer without complication and therefore should be considered for patients without a rectum., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We report the case of a 66-year-old previously healthy man presenting with blood and mucus in his urine. Cystoscopy revealed a mass in the prostatic urethra, and endoscopic biopsy showed adenocarcinoma in situ with mucinous features. Endorectal multiparametric prostate MRI demonstrated a 1.9 cm T2 hyperintense mass in the peripheral zone of the left prostatic apex with extension into the urethral lumen. No diffusion restriction or early enhancement was seen in the mass. Radical prostatectomy was performed, and final pathology demonstrated a mucin-producing urothelial adenocarcinoma arising from the prostatic urethra. The peripheral zone T2 hyperintense abnormality correlated with abundant pools of mucin extending into the prostatic stroma and surrounded by neoplastic prostatic glandular cells. We conclude prostatic urethral mucinous urothelial carcinoma should be included in the differential diagnosis for T2 hyperintense prostatic masses., (Copyright © 2020. Published by Elsevier Inc.)

We report a 44 year old previously healthy premenopausal woman who presented with a three month history of vaginal bleeding and a 5 cm vaginal mass obscuring the cervix on physical examination. Ultrasound evaluation was non diagnostic. Pelvic MRI demonstrated a 6 cm soft tissue mass in the vagina prolapsed from the uterine cavity with a visible connecting stalk, which is termed the broccoli sign. The initial radiological differential diagnosis included prolapsed uterine malignancy or leiomyoma. Surgical pathology revealed a polypoid adenomyoma. We conclude polypoid adenomyoma should be included in the differential diagnosis for prolapsed uterine tumor demonstrating the broccoli sign., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To investigate the concordance between dominant intraprostatic cancer seen on endorectal multiparametric MRI and confirmed by MRI-targeted biopsy with histopathological findings at radical prostatectomy, since existing literature has emphasized the miss rather than the concordance rate of MRI., Materials and Methods: We retrospectively identified 20 patients who underwent radical prostatectomy after a dominant intraprostatic cancer focus was identified at endorectal multiparametric MRI and confirmed by MRI-targeted biopsy. Concordance was determined by comparing the location and Gleason grade group of dominant tumor at MRI with the location and Gleason grade group determined at histopathological review., Results: Mean patient age was 65 years (range, 48 to 76) and median serum prostatic specific antigen level was 9.4 ng/mL (range, 4.6 to 58.0). In all 20 patients, the location of dominant tumor based on MRI and targeted biopsy corresponded with the dominant tumor location at histopathology. In 9 patients, Gleason grade group was the same at targeted biopsy and final histopathology. In 9 patients, final Gleason grade group was higher and in two patients it was lower., Conclusion: Our preliminary results suggest dominant tumor as determined by endorectal multiparametric MRI and confirmed by a positive MRI-targeted biopsy has high concordance with histopathological findings at radical prostatectomy for location, and reasonable concordance for Gleason grade group., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The radiological differential diagnosis for complex renal cysts seen at CT generally includes cystic malignancy or renal abscess. We have encountered five cases of complex-appearing renal cysts at CT where serial imaging and clinical outcome favored a diagnosis of a collapsed benign simple renal cyst. We present these cases to broaden the differential diagnosis for complex renal cysts seen at CT, highlighting the importance of careful correlation with prior imaging to assist in correct recognition of collapsed simple cysts and potentially allowing for conservative management or surveillance., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To evaluate the length of contact between dominant tumor foci and the prostatic capsule as a sign of extracapsular extension at endorectal multiparametric MR imaging., Materials and Methods: We retrospectively identified 101 patients over a three-year interval who underwent endorectal multiparametric prostate MR imaging prior to radical prostatectomy for prostate cancer. Two readers identified the presence of dominant tumor focus (largest lesion with PI-RADS version 2 score of 4 or 5), and measured the length of tumor capsular contact and likelihood of extracapsular extension by standard criteria (1-5 Likert scale). Results were analyzed using histopathological review as reference standard., Results: Extracapsular extension was found at histopathological review in 27 patients. Reader 1 (2) identified dominant tumor in 79 (73) patients, with mean tumor capsular contact length of 18.2 (14.0) mm. The area under the receiver operating characteristic curve for identification of extracapsular extension by tumor capsular contact length was 0.76 for reader 1 and 0.77 for reader 2, with optimal discrimination at values of 18 mm and 21 mm, respectively. In the subset of patients without obvious extracapsular extension by standard criteria (Likert scores 1-3), corresponding values were 0.74 and 0.66 with optimal thresholds of 24 and 21 mm., Conclusion: Length of contact between the dominant tumor focus and the capsule is a moderately useful sign of extracapsular extension at endorectal multiparametric prostate MR imaging, including the subset of patients without obvious extracapsular extension by standard criteria, with optimal discrimination at threshold values of 18 to 24 mm., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Clinicopathological correlates of prostate cancer associated with a pseudocapsule at T2-weighted magnetic resonance (MR) imaging are presented in a retrospective series of 15 patients. Of 15 tumors, 14 involved the peripheral zone. Extracapsular extension was seen in 14 cases. Tumor Gleason score was 8 or above in 12 of 15 cases, and ductal type adenocarcinoma was identified in 4 cases. Step section histopathological correlation (n=5) demonstrated that the pseudocapsule corresponded with dense compressive or reactive peritumoral fibrosis. A pseudocapsule around prostate cancer at T2-weighted MR imaging is a rare finding that appears to be associated with high grade and stage disease., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the incremental effect of perfusion imaging on biopsy target identification at endorectal multiparametric prostate magnetic resonance imaging (MRI)., Materials and Methods: We retrospectively 52 patients who underwent endorectal multiparametric prostate MRI for suspected or untreated prostate cancer. Two readers independently identified biopsy targets without and with perfusion images., Results: Reader 1 identified 36 targets without and 39 targets with perfusion imaging (P>.05). The corresponding numbers for reader 2 were 38 and 38, respectively (P=.5)., Conclusion: Perfusion imaging does not significantly increase the number of biopsy targets identified at endorectal multiparametric prostate MRI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Imaging findings in a patient with invasive thymoma in the costophrenic recess are presented, in whom computed tomography (CT) and MRI revealed lateral arcuate ligament thickening. Increased fluoro-deoxy-glucose (FDG) uptake on subsequent positron emission tomography (PET)/CT was helpful in suggesting the correct diagnosis. A second patient with much more obvious invasive thymoma occurring in the costophrenic recess is presented for comparison. It is a well-known fact that thymic malignancies can metastasize to the pleura even years after resection. Rarely, they may present as focal thickening of the diaphragmatic lateral arcuate ligament., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We report a 57-year-old previously healthy man who presented with dull right upper quadrant pain, weight loss, fatigue, and night sweats. Computed tomography demonstrated a large, heterogeneously enhancing, soft tissue mass with no macroscopic fat above the right kidney with tumor thrombus extending into the inferior vena cava and right atrium. Positron Emission Tomography scanning demonstrated intense Fluorodeoxyglucose avidity in the primary tumor and tumor thrombus. The presumptive radiological diagnosis was adrenocortical carcinoma, but surgical pathology revealed a dedifferentiated liposarcoma. We conclude that suprarenal retroperitoneal liposarcoma should be included in the differential diagnosis for an apparent adrenal mass with venous invasion., (© 2014.)

Purpose: To investigate diagnostic accuracy for acute appendicitis at computed tomography (CT) as a performance metric for radiologists specialized in abdominal imaging., Materials and Methods: We retrospectively identified six attending abdominal imagers who each independently interpreted over 100 CT studies for suspected acute appendicitis., Results: The mean number of studies per reader was 311 (range, 129-386). Mean reader diagnostic accuracy was 95.0% (range, 91.4-97.1%). Only one had a diagnostic accuracy (91.4%) that was significantly lower than all others., Conclusion: Diagnostic accuracy for acute appendicitis at CT may be an impractical performance metric for radiologists specialized in abdominal imaging., (© 2014.)

Objective: To evaluate the presence of renal cyst pseudoenhancement at 16- and 64-row multidetector computed tomography (MDCT) in patients., Methods: MDCT images from 90 patients with renal cysts >1 cm in diameter (n=122) were retrospectively analyzed for the presence and predictors of cyst pseudoenhancement., Results: Fifty-three percent of cysts 1-2 cm demonstrated pseudoenhancement (ranged from 11 to 35 HU). Cyst pseudoenhancement was more pronounced when imaged with 64-row CTs compared to 16-row CT. Cyst size, postcontrast renal parenchymal density, and number of scanner detector rows were independent predictors of pseudoenhancement., Conclusion: Pseudoenhancement occurs most frequently in patients with renal cysts <2 cm imaged with 64-detector-row MDCT., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To review the imaging findings in late complications of cholecystectomy., Conclusions: Late postcholecystectomy complications include papillary stenosis, choledocholithiasis, biliary stricture, remnant gallbladder, and dropped gallstones. Such complications can cause substantial morbidity, and knowledge of the imaging appearances can facilitate expeditious diagnosis and treatment., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare the accuracy of T2-weighted magnetic resonance (MR) imaging and transrectal ultrasound (TRUS) for staging of prostate cancer., Material and Methods: A total of 101 men with biopsy-proven prostate cancer undergoing both T2-weighted endorectal MR imaging and B-mode TRUS for local tumor staging prior to radical prostatectomy were retrospectively identified. Three MR readers rated the likelihood of locally advanced disease using a 5-point scale. An ultrasound reader performed the same rating. Staging accuracy was compared using receiver operating characteristic curves., Results: Staging accuracy was not significantly different between MR imaging (A(z) = 0.69-0.70) and TRUS (A(z) = 0.81, P>.05)., Conclusions: T2-weighted MR imaging demonstrates comparable accuracy to B-mode TRUS for depicting locally invasive prostate cancer., (Published by Elsevier Inc.)

We retrospectively reviewed the records of 153 patients with breast cancer undergoing serial abdominal computed tomography (CT). During a median follow-up of 40 months, 2 (1.4%) of 153 patients developed bilateral hydronephrosis in the absence of radiologically visible obstructing pathology. Surgery confirmed malignant infiltration of the ureters by metastatic lobular carcinoma in both patients, suggesting that new unexplained bilateral hydronephrosis on serial CT in patients with breast cancer is likely to reflect infiltrative retroperitoneal involvement of the ureters by metastatic lobular carcinoma., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Modern chemotherapy may result in an array of complications that can produce computed tomography (CT) findings in the hepatobiliary, gastrointestinal and urinary systems. This article describes the CT findings that may be seen in abdominal complications of contemporary chemotherapy. Knowledge of the varying CT appearances that can be encountered may facilitate both diagnosis and management in such cases., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In a retrospective study of 71 voxels of benign peripheral zone tissue from 3 men who underwent endorectal magnetic resonance (MR) spectroscopic imaging of the prostate at both 1.5 and 3 T, 21 voxels that appeared more malignant at 3 T to either of two readers demonstrated significantly higher levels of choline and polyamines at 3 T compared to 1.5 T using a Wilcoxon ranked-sum test; awareness of this selective amplification of these metabolic signals at high field strength may help avoid overdiagnosis of prostate cancer., (Copyright © 2011. Published by Elsevier Inc.)

Background: Prior studies have described a pseudocalculus appearance in the distal common bile duct as a normal variant at cholangiography. The objective of this study was to describe the occurrence of pseudotumor in the distal common bile duct at endoscopic retrograde cholangiopancreatography (ERCP)., Methods: Nine patients who underwent ERCP between May 2004 and July 2008 were identified as having a transient eccentric mural-based filling defect in the distal common bile duct. A single reader systematically reviewed all studies and recorded the imaging findings., Results: The mean diameter of the filling defect was 9 mm (range, 5 to 11). Eight patients had resolution of the filling defect during the same ERCP or on a subsequent ERCP, and in two of these patients the inferior border of the filling defect was not well visualized. The other patient underwent surgical resection of a presumed tumor with no evidence of malignancy on surgical pathology., Conclusion: An eccentric mural-based filling defect in the distal common bile duct can be artifactual in nature and may reflect transient contraction of the sphincter of Oddi. Recognition of this pseudotumor may help avoid unnecessary surgery., (Copyright © 2011 Elsevier Inc. All rights reserved.)

We retrospectively identified eight patients who underwent F-18 FDG PET/CT and had diagnostic findings of postradiation pelvic insufficiency fracture. The fractures had a median SUV(max) of 2.5 (range, 1.6 to 6.0) and were initially interpreted as possible metastases in six patients. A new bone lesion developing in the sacrum, pubic ramus, or acetabulum after radiation for pelvic malignancy is likely to be a postradiation pelvic insufficiency fracture, even if associated with increased FDG uptake at PET., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Two patients with renal cell carcinoma and one patient with metastasis to the kidney from colorectal cancer are reported because all three cases manifested at computed tomography (CT) as a renal mass invading the pelvicaliceal system and radiologically simulating transitional cell carcinoma. Recognition that the CT finding of a renal mass with invasion of the pelvicaliceal system is not always indicative of a transitional cell carcinoma broadens the differential diagnosis in this setting and might potentially alter the diagnostic and therapeutic approach., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The primary computed tomography (CT) signs of appendicitis can also be seen with other inflammatory or neoplastic processes. We report on two cases in which appendiceal dilatation and peri-appendiceal fluid or stranding were the dominant imaging manifestations of colorectal carcinoma in the ascending colon. This study highlights the need to closely examine the ascending colon in patients with a suspected CT diagnosis of acute appendicitis, since these findings may be secondary to an inconspicuous colorectal carcinoma.

Purpose: To evaluate whether supine or prone positioning improves pelvicalyceal and ureteral opacification at multi-detector row computed tomographic (CT) urography., Methods: We retrospectively reviewed the CT urograms of 114 consecutive patients performed for hematuria. Using a "split-bolus" technique, all patients were imaged 340 s after the injection of intravenous contrast, 63 in the supine and 51 in the prone position. The right and left pelvicalyceal systems and ureters were divided into six segments: anterior calyces, posterior calyces, renal pelvis, proximal ureter, mid ureter, and distal ureter. Two readers rated the opacification of each segment in consensus on a four-point scale from 0 (no opacification) to 3 (excellent opacification). Opacification scores were compared between supine and prone CT urograms using generalized estimating equation models., Results: Supine positioning resulted in higher opacification scores of the renal pelvis and the posterior calyces than prone positioning (P<.01). Prone positioning resulted in higher opacification scores of the anterior calyces only (P<.01). No significant differences were seen between the supine and prone opacification scores for the proximal, mid, or distal ureters (P values all >.5)., Conclusion: Supine positioning results in overall greater opacification of the pelvicalyceal system compared to prone positioning at CT urography.

Purpose: To determine if small hypoattenuating renal masses can be characterized as simple cysts or renal cell carcinomas on contrast-enhanced computed tomography (CT)., Materials and Methods: We retrospectively identified 20 small (

The purpose of this study was to describe the CT appearance and determine the prevalence of thick-walled appendices in patients with an extraintestinal primary malignancy. This potential mimic of appendicitis may occur in up to 2% of cancer patients. Awareness of this pitfall is important to avoid unnecessary laparotomy in this patient population.

Purpose: To compare ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) determination of diffuse liver steatosis., Materials and Methods: Quantification of liver steatosis on ultrasound, CT, and MRI was correlated with histopathology in 67 patients., Results: Opposed-phase MRI demonstrated the highest correlation with steatosis (0.68 and 0.69, P<.01; intraclass correlation coefficient, 0.93). Spearman's correlation (and intraclass correlation) coefficients were lowest for ultrasound [0.54, 0.33 (0.40)] and enhanced CT [0.33, 0.39 (0.97)]., Conclusion: Opposed-phase MRI demonstrated best overall performance for determining steatosis.

Purpose: To determine the frequency and etiology of a single hypermetabolic focus within the pelvis with no other areas of increased 18-fluorodeoxyglucose (FDG) uptake in the reminder of the whole body in an oncological population., Method and Materials: We retrospectively examined the first 700 whole-body PET/CT scans performed at our institution for baseline staging or follow-up of cancer and identified all patients with a solitary focus of increased FDG uptake in the pelvis. All available medical records and imaging findings in these patients were reviewed in order to determine the etiology of increased FDG uptake., Results: Eight (1.1%) of the 700 patients had a solitary hot spot in the pelvis at positron emission tomography (PET)/computed tomography (CT) imaging, consisting of seven of 380 women and one of 320 men. In the seven women, increased FDG uptake was due to physiological endometrial uptake (n=2), leiomyoma (n=1), corpus luteum cyst (n=1), physiological ovarian uptake (n=1), urinary leak (n=1), and nonspecific colitis (n=1). In the man, uptake was due to recurrent rectosigmoid adenocarcinoma. None of the 700 patients was found to have metastatic disease in the pelvis., Conclusion: Isolated pelvic hot spots at PET/CT imaging in an oncological population are not common and usually benign; physiological endometrial or ovarian uptake is the single commonest cause.

We present CT imaging findings with pathologic correlation in a rare case of a solitary fibrous tumor arising in the pelvis in a 34-year-old man. This tumor presented as a hypervascular heterogeneously enhancing deep pelvic mass at CT. Although CT initially suggested the prostate as the site of origin for this tumor, no prostate involvement was found at surgery; CT accurately excluded bladder and rectal involvement.

Pelvic masses are increasingly evaluated by computed tomography and magnetic resonance imaging. Existing literature predominantly addresses common bladder, prostate, or gynecologic masses, with scant radiologic literature on less common pelvic masses. This article highlights the imaging features of some uncommon pelvic masses and emphasizes findings of particular diagnostic or clinical utility. Certain imaging findings can suggest specific diagnoses or can narrow the differential diagnosis.

Purpose: This study aimed to determine the frequency of hepatic contour abnormalities and signs of portal hypertension at serial CT in patients receiving chemotherapy for breast cancer metastatic to the liver., Materials and Methods: We retrospectively identified 91 women with breast cancer metastatic to the liver who received chemotherapy and underwent serial CT at our institution between 1998 and 2002. Two readers independently categorized hepatic contour abnormalities on the final CT examination as none, limited retraction, widespread retraction, or diffuse nodularity. Readers also recorded the development of hepatic atrophy or enlargement, ascites, portosystemic collateral veins, and splenomegaly. Interpretative discrepancies were resolved by consensus. Portal hypertension was defined as the presence of at least two of the following CT signs: simple ascites, portosystemic collateral veins, and splenomegaly., Results: After a median follow-up interval of 15 months (range, 1-46), hepatic contour abnormalities were seen in 68 of 91 patients (75%) and consisted of limited retraction (n = 42), widespread retraction (n = 10), or diffuse nodularity (n = 16). Portal hypertension was found in 1 of 23 patients without contour abnormalities, in 1 of 42 patients with limited retraction, in none of 10 patients with widespread retraction, and in 6 of 16 patients with diffuse nodularity (P < .01)., Conclusion: Hepatic contour abnormalities commonly develop at serial CT in patients undergoing chemotherapy for breast cancer metastatic to the liver and may be accompanied by signs of portal hypertension; the latter are particularly, but not exclusively, associated with the development of diffuse hepatic nodularity.

Midesophageal diverticula were identified at 8 of 218 (3.6%) esophagrams performed over a 3-year period in adult patients with no prior history of gastroesophageal surgery. All eight patients received a final diagnosis of esophageal dysmotility with secondary pulsion diverticula, and seven of eight (88%) patients had abnormal peristalsis noted during the esophagram. We conclude that most, if not all, midesophageal diverticula are pulsion in etiology, and the detection of a midesophageal diverticulum should prompt a careful search for underlying dysmotility.