Bringing radiology to patient's home using mobile equipment: A weapon to fight COVID-19 pandemic

Because of coronavirus disease 2019 (COVID-19) high contagiousness, it is crucial to identify and promptly isolate COVID-19 patients. In this context, chest imaging examinations, in particular chest x-ray (CXR), can play a pivotal role in different settings, to triage in case of unavailability, delay of or first negative result of reverse transcriptase-polymerase chain reaction (RT-PCR), and to stratify disease severity. Considering the need to reduce, as much as possible, hospital admission of patients with suspected or confirmed infection, the use of mobile x-ray equipment could represent a safe approach. We picture a potential sequence of events, involving a team composed by a radiographer and a nurse, going to patient's home to perform CXR, nasopharyngeal swab (and, if needed, also a blood sample), with fast radiologist tele-reporting, and resulting patient management approach (home isolation or emergency room admission, when needed). This approach brings healthcare to patient's home, reducing the risk of infected subjects referring to family doctors' office or emergency departments, and strengthening community medicine while maintaining a strong connection with radiology departments.

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Chest x-ray and computed tomography can play a pivotal role in COVID-19 pandemic.

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Mobile x-ray at patient's house or nursing home could represent a safe approach reducing social contacts during pandemic.

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Domiciliary radiography reduces the risk of infected subjects referring to family doctors’ office or emergency departments.

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This procedure can reduce general practitioner visit, nurse performing swab and transportation to the hospital costs.

An update on the management of breast atypical ductal hyperplasia

Among lesions with uncertain malignant potential found at percutaneous breast biopsy, atypical ductal hyperplasia (ADH) carries both the highest risk of underestimation and the closest and most pathologist-dependent differential diagnosis with ductal carcinoma in situ (DCIS), matching the latter's features save for size only. ADH is therefore routinely surgically excised, but single-centre studies with limited sample size found low rates of upgrade to invasive cancer or DCIS. This suggests the possibility of surveillance over surgery in selected subgroups, considering the 2% threshold allowing for follow-up according to the Breast Imaging Reporting and Data System. A recent meta-analysis on 6458 lesions counters this approach, confirming that, surgically excised or managed with surveillance, ADH carries a 29% and 5% upgrade rate, respectively, invariably higher than 2% even in subgroups considering biopsy guidance and technique, needle calibre, apparent complete lesion removal. The high heterogeneity (I2 = 80%) found in this meta-analysis reaffirmed the need to synthesise evidence from systematic reviews to achieve generalisable results, fit for guidelines development. Limited tissue sampling at percutaneous biopsy intrinsically hampers the prediction of ADH-associated malignancy. This prediction could be improved by using contrast-enhanced breast imaging and applying artificial intelligence on both pathology and imaging results, allowing for overtreatment reduction.

CT-derived pulmonary vascular metrics and clinical outcome in COVID-19 patients

To assess pulmonary vascular metrics on chest CT of COVID-19 patients, and their correlation with pneumonia extent (PnE) and outcome, we analyzed COVID-19 patients with an available previous chest CT, excluding those performed for cardiovascular disease. From February 21 to March 21, 2020, of 672 suspected COVID-19 patients from two centers who underwent CT, 45 RT-PCR-positives (28 males, median age 75, IQR 66-81 years) with previous CTs performed a median 36 months before (IQR 12-72 months) were included. We assessed PnE, pulmonary artery (PA) diameter, ascending aorta (Ao) diameter, and PA/Ao ratio. Most common presentations were fever and dyspnea (15/45) and fever alone (13/45). Outcome was available for 41/45 patients, 15/41 dead and 26/41 discharged. Ground-glass opacities (GGOs) alone were found in 29/45 patients, GGOs with consolidations in 15/45, consolidations alone in 1/45. All but one patient had bilateral pneumonia, 9/45 minimal, 22/45 mild, 9/45 moderate, and 5/45 severe PnE. PA diameter (median 31 mm, IQR 28-33 mm) was larger than before (26 mm, IQR 25-29 mm) (P<0.001), PA/Ao ratio (median 0.83, IQR 0.76-0.92) was higher than before (0.76, IQR 0.72-0.82) (P<0.001). Patients with adverse outcome (death) had higher PA diameter (P=0.001), compared to discharged ones. Only weak correlations were found between ΔPA or ΔPA/Ao and PnE (ρ≤0.453, P≤0.032), with 4/45 cases with moderate-severe PnE and minimal increase in PA metrics. In conclusion, enlarged PA diameter was associated to death in COVID-19 patients, a finding deserving further investigation as a potential driver of therapy decision-making.

Breast ultrasound: automated or hand-held? Exploring patients' experience and preference

Background

Our aim was to compare women’s experience with automated breast ultrasound (ABUS) versus breast hand-held ultrasound (HHUS) and to evaluate their acceptance rate.

Methods

After ethical approval, from October 2017 to March 2018, 79 consecutive patients were enrolled in this prospective study. On the same day, patients underwent HHUS followed by ABUS. Each patient’s experience was assessed using the modified testing morbidities index (TMI) (the lower the score, the better is the experience). Nine items were assessed for both techniques: seven directly related to the examination technique (pain or discomfort immediately before (preparation), during and after testing, fear or anxiety immediately before (preparation) and during testing, physical and mental function after testing) and two indirectly related to the examination technique (embarrassment during testing and overall satisfaction). Finally, we asked patients to choose between the two techniques for a potential next breast examination. Wilcoxon signed ranks test was used.

Results

The median TMI score for the seven items was found to be significantly better for HHUS (8, interquartile range [IQR] 7–11) compared to ABUS (9, IQR 8–12) (p = 0.003). The item ‘pain/discomfort during the test’ (p < 0.001) was significantly higher for ABUS compared to HHUS. Instead, the item ‘fear/anxiety before the test’ was higher for HHUS (p = 0.001). Overall, 40.5% of the patients chose HHUS, 29.1% chose ABUS, and 30.4% were unable to choose.

Conclusions

ABUS and HHUS exams were well tolerated and accepted. However, HHUS was perceived to be less painful than ABUS.

Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as "high-risk" or B3 lesions). Finally, seven frequently asked questions are answered.

Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions

Background Management of percutaneously diagnosed pure atypical ductal hyperplasia (ADH) is an unresolved clinical issue. Purpose To calculate the pooled upgrade rate of percutaneously diagnosed pure ADH. Materials and Methods A search of MEDLINE and EMBASE databases was performed in October 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines were followed. A fixed- or random-effects model was used, along with subgroup and meta-regression analyses. The Newcastle-Ottawa scale was used for study quality, and the Egger test was used for publication bias. Results Of 521 articles, 93 were analyzed, providing data for 6458 ADHs (5911 were managed with surgical excision and 547 with follow-up). Twenty-four studies used core-needle biopsy; 44, vacuum-assisted biopsy; 21, both core-needle and vacuum-assisted biopsy; and four, unspecified techniques. Biopsy was performed with stereotactic guidance in 29 studies; with US guidance in nine, with MRI guidance in nine, and with mixed guidance in eight. Overall heterogeneity was high (I² = 80%). Subgroup analysis according to management yielded a pooled upgrade rate of 29% (95% confidence interval [CI]: 26%, 32%) for surgically excised lesions and 5% (95% CI: 4%, 8%) for lesions managed with follow-up (P < .001). Heterogeneity was entirely associated with surgically excised lesions (I² = 78%) rather than those managed with follow-up (I² = 0%). Most variability was explained by guidance and needle caliper (P = .15). At subgroup analysis of surgically excised lesions, the pooled upgrade rate was 42% (95% CI: 31%, 53%) for US guidance, 23% (95% CI: 19%, 27%) for stereotactic biopsy, and 32% (95% CI: 22%, 43%) for MRI guidance, with heterogeneity (52%, 63%, and 56%, respectively) still showing the effect of needle caliper. When the authors considered patients with apparent complete lesion removal after biopsy (subgroups in 14 studies), the pooled upgrade rate was 14% (95% CI: 8%, 23%). Study quality was low to medium; the risk of publication bias was low (P = .10). Conclusion Because of a pooled upgrade rate higher than 2% (independent of biopsy technique, needle size, imaging guidance, and apparent complete lesion removal), atypical ductal hyperplasia diagnosed with percutaneous needle biopsy should be managed with surgical excision. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Brem in this issue.

Technique, protocols and adverse reactions for contrast-enhanced spectral mammography (CESM): a systematic review

We reviewed technical parameters, acquisition protocols and adverse reactions (ARs) for contrast-enhanced spectral mammography (CESM). A systematic search in databases, including MEDLINE/EMBASE, was performed to extract publication year, country of origin, study design; patients; mammography unit/vendor, radiation dose, low-/high-energy tube voltage; contrast molecule, concentration and dose; injection modality, ARs and acquisition delay; order of views; examination time. Of 120 retrieved articles, 84 were included from 22 countries (September 2003-January 2019), totalling 14012 patients. Design was prospective in 44/84 studies (52%); in 70/84 articles (83%), a General Electric unit with factory-set kVp was used. Per-view average glandular dose, reported in 12/84 studies (14%), ranged 0.43-2.65 mGy. Contrast type/concentration was reported in 79/84 studies (94%), with Iohexol 350 mgI/mL mostly used (25/79, 32%), dose and flow rate in 72/84 (86%), with 1.5 mL/kg dose at 3 mL/s in 62/72 studies (86%). Injection was described in 69/84 articles (82%), automated in 59/69 (85%), manual in 10/69 (15%) and flush in 35/84 (42%), with 10-30 mL dose in 19/35 (54%). An examination time < 10 min was reported in 65/84 studies (77%), 120 s acquisition delay in 65/84 (77%) and order of views in 42/84 (50%) studies, beginning with the craniocaudal view of the non-suspected breast in 7/42 (17%). Thirty ARs were reported by 14/84 (17%) studies (26 mild, 3 moderate, 1 severe non-fatal) with a pooled rate of 0.82% (fixed-effect model). Only half of CESM studies were prospective; factory-set kVp, contrast 1.5 mL/kg at 3 mL/s and 120 s acquisition delay were mostly used; only 1 severe AR was reported. CESM protocol standardisation is advisable.

Correction to: Point estimate and reference normality interval of MRI-derived myocardial extracellular volume in healthy subjects: a systematic review and meta-analysis

The original version of this article, published on 02 May 2019, unfortunately contained a mistake. The following correction has therefore been made in the original: The presentation of Fig. 2 was incorrect. The corrected figure is given below. The original article has been corrected.

Ultrasonography as first line imaging for the diagnosis of positional plagiocephaly: our experience and literature review

BACKGROUND

In the last years, numerous studies evaluated different tools for the diagnosis of positional plagiocephaly (PP). The purpose of this study was to evaluate ultrasonography (US) as a first line screening test of lambdoid sutural patency in child with PP and to compare our results with the literature.

MATERIALS AND METHODS

All consecutive patients who referred to our Institute from January 2016 to October 2017 with the suspicion of PP, were included in the study and performed US examination of the lambdoid sutures. A 3-6 month clinical follow up was performed by a paediatric neurosurgeon or a paediatrician to confirm the diagnosis of PP.

RESULTS

Thirty-five children performed US examination and in all cases the diagnosis of PP was confirmed. No cases of anticipated suture fusion were examined during this period. The concordance between US findings and clinical exam follow-up was 100%.

CONCLUSIONS

Ultrasonography of the lambdoid sutures represents an ideal first-line screening test and reliable alternative to other diagnostic techniques for lambdoid sutural patency in child with PP, being radiation free, fast and cheap.

Role of Strain Elastography and Shear-Wave Elastography in a Multiparametric Clinical Approach to Indeterminate Cytology Thyroid Nodules

Background

In thyroid nodules with indeterminate cytology, further clinical assessment aimed at ruling out malignancy is often mandatory. Ancillary imaging techniques and genetic mutation analysis can improve the risk stratification of such lesions, thereby facilitating the clinician’s decision to undertaken surgery or simple follow-up. The aim of this study was to evaluate the diagnostic performance of shear-wave elastography (SW), strain elastography (ELX 2/1), conventional ultrasound (US), contrast-enhanced ultrasound (CEUS), and BRAF V600E mutation analysis in the aforementioned lesions.

Material/Methods

We enrolled 81 patients, each with 1 indeterminate-cytology thyroid nodule. Thyroid function, thyroperoxidase antibodies and calcitonin were known in each case. SW, ELX 2/1, US, CEUS, and BRAF mutation analysis were subsequently performed, followed by a second FNAB. If the lesion was not downgraded to benign, surgery was recommended and histological reports collected.

Results

There were 28 nodules (34%) that proved benign on the second FNAB; 38 nodules (47%) underwent surgery (17 benign, 21 malignant), and 15 nodules (19%) refused surgery. The only techniques related to histological outcome were US (AUC=0,766), ELX 2/1 (AUC=0.701), and BRAF analysis (AUC=0.762). ELX 2/1 and SW reports were not correlated with each other (P=0.45). A scoring system taking into account all the variables considered performed better than the single variables alone (AUC=0.831).

Conclusions

In indeterminate-cytology thyroid lesions, repeating FNAB can avoid unnecessary surgery. ELX 2/1 seems to perform better than SW in distinguishing malignancy; these techniques could, however, be complementary in describing such lesions. A multiparametric approach appears the most accurate in predicting nodule histology.

Retrospective cytological evaluation of indeterminate thyroid nodules according to the British Thyroid Association 2014 classification and comparison of clinical evaluation and outcomes

The cytology of 130 indeterminate nodules (Thy 3) was retrospectively reviewed according to the British Thyroid Association 2014 classification. Nodules were divided into Thy 3a (atypical features) and Thy 3f (follicular lesion) categories. Histology was available as a reference for 97 nodules. Pre-surgical evaluations comprised biochemical tests, color-Doppler ultrasonography (US), semi-quantitative elastography-US (USE), contrast-enhanced US (CEUS), and mutation analysis from cytological slides. Thyroid malignancy was the final diagnosis for 19% of surgically-treated nodules. No statistically significant difference in the risk of malignancy was found between Thy 3a (26%) and Thy 3f (14%) nodules. Histology of the Thy 3a and Thy 3f nodules showed a higher incidence of Hurtle cell adenomas in Thy 3f (29%) than in Thy 3a (3%) nodules (P=0.01). The only pre-surgical difference concerned the BRAF V600E mutation, which was positive in some Thy 3a but not in any Thy 3f nodules (P=0.04). Receiver-operating characteristic (ROC) analysis was used to obtain cut-off values from US (score), USE (ELX 2/1 strain index), and CEUS (time-to-peak index and peak index) data. The cut-off values were similar for Thy 3a and Thy 3f nodules. Data showed that malignancy can be suspected if the US score is >2, ELX 1/2 strain index >1, time-to-peak index >1, and peak index <1. In a sub-group of 24 revised nodules (12 Thy 3a and 12 Thy 3f) with histology as a reference, the diagnostic power of cumulative pre-surgical analysis by means of US, USE, and CEUS showed high positive and negative predictive values (83% and 100%, respectively) for the presence of malignancy in Thy 3a and Thy 3f nodules. In conclusion, in our series of revised Thy 3 nodules, malignancy was low and displayed no significant differences between Thy 3a and Thy 3f categories. The use of cut-offs based on histology as a reference could reduce surgery. Our data support the conviction that, in mutation-negative Thy 3a and Thy 3f nodules, observation should be the first choice when not all instrumental results are suspect.

Vacuum assisted breast biopsy (VAB) excision of subcentimeter microcalcifications as an alternative to open biopsy for atypical ductal hyperplasia

OBJECTIVE

Atypical ductal hyperplasia (ADH) is a proliferative lesion associated with a variable increased risk of breast malignancy, but the management of the patients is still not completely defined, with mandatory surgical excision in most cases. To report the results of the conservative management with mammographic checks of patients with ADH diagnosed by vacuum assisted breast biopsy (VAB), without residual calcifications.

METHODS

The authors accessed the institutional database of radiological, surgical and pathological anatomy. Inclusion criteria were: ADH diagnosed by VAB on a single group of microcalcifications, without residual post-procedure; follow-up at least of 12 months. Exclusion criteria were the presence of personal history of breast cancer or other high-risk lesions; association with other synchronous lesions, both more and less advanced proliferative lesions.

RESULTS

The 65 included patients were all females, with age range of 40-79 years (mean 54 years). The maximum diameter range of the groups of microcalcifications was 4-11 mm (mean 6.2 mm), all classified as BI-RADS 4b (Breast Imaging Reporting and Data System 4b) and defined as fine pleomorphic in 29 cases (45%) or amorphous in 36 cases (55%). The range of follow-up length was 12-156 months (mean 67 months). Only one patients developed new microcalcifications, in the same breast, 48 months after and 15 mm from the first VAB, interpreted as low-grade ductal carcinoma in situ (DCIS) at surgical excision.

CONCLUSION

These results could justify the conservative management, in a selected group of patients, being the malignancy rate lower than 2%, considered in the literature as the "probably benign" definition. Advances in knowledge: Increasing the length of follow-up of selected patients conservatively managed can improve the management of ADH cases.

Flat epithelial atypia: conservative management of patients without residual microcalcifications post-vacuum-assisted breast biopsy

OBJECTIVE

To determine the malignancy rate (defined in this study as stability or absence of malignancy developed on close imaging follow-up post-biopsy) of conservative management in patients with a vacuum-assisted breast biopsy (VAB) diagnosis of flat epithelial atypia (FEA), performed on single group of microcalcifications, completely removed during procedure.

METHODS

This is a retrospective, monocentric, observational study, approved by IRB. Inclusion criteria were: VAB performed on a single group of microcalcifications; the absence of residual calcifications post-VAB; diagnosis of isolated FEA as the most advanced proliferative lesion; radiological follow-up at least of 12 months. The personal history of breast cancer or other high-risk lesions was an exclusion criteria. The patients enrolled were conservatively managed, without surgical excision, through close follow-up: the first two mammographies performed with an interval of 6 months after biopsy, followed by annual mammographic and clinical checks.

RESULTS

48 consecutive patients were enrolled in the study, all females, with age range of 39-76 years (mean 53,3 years) and radiological follow-up range of 13-75 months (mean 41.5 months). All the lesions were classified as BI-RADS 4b. The diameter range of the group of calcifications was 3-10 mm (mean 5, 6 mm). In each patient, 7 to 15 samples (mean 11) were obtained. Among all the patients, there was only one case (2%) of new microcalcifications, developed in the same breast, 26 months after and 8 mm from the site of previous VAB, and interpreted as ADH at surgical excision. All the checks of the other patients were negative.

CONCLUSION

Even with a limited follow-up, we found a malignancy rate lower than 2%, through a defined population. Further studies with bigger number of patients and extended follow-up are needed to reinforce this hypothesis. Advances in knowledge: Surgical excision may not be necessary in patients with VAB diagnosis of isolated FEA, without residual microcalcifications post-procedure and considered concordant with the mammographic presentation, considering the low rate of malignancy at subsequent follow-ups.

In vivo feasibility of real-time MR-US fusion imaging lumbar facet joint injections

OBJECTIVES

Traditionally, facet joint injections (FJI) are performed under fluoroscopic or computed tomography (CT) guidance, mainly due to the deep anatomical location and the presence of bony landmarks. Fusion imaging technology, which couples the ultrasound scan with the corresponding CT or magnetic resonance (MR) image obtained from the diagnostic examination and reformatted in real time according to the ultrasound scanning plane, allows to combine the panoramic view and the elevated anatomical detail of MR or CT with the ease of use of ultrasound without patient exposure to ionizing radiation.

METHODS

Thirty eight patients (24 females; mean age ± SD: 64 ± 9 years) received MR fusion-assisted ultrasound-guided FJI of 1 ml of a mixture of local anaesthetic and corticosteroid using a ultrasound machine (Logiq E9, GE Healthcare) equipped with a GPS-enhanced fusion imaging technology which couples real-time B-mode images with those of the previous recent diagnostic MR examination. Low-dose CT needle positioning confirmation was performed in the first 28 patients. Patients' pain was recorded using a visual analogue scale (VAS), at baseline and at 2, 4 and 8 weeks.

RESULTS

All fusion imaging-guided injections were performed successfully. Out of 112, 96 FJI had optimal intra-articular needle positioning (accuracy: 85.7%). Patients VAS significantly decreases after the procedure with no differences among who received CT needle positioning control and who did not receive it. No major complications were observed.

CONCLUSIONS

Ultrasound needle guidance with MR fusion assistance allows for safe and effective injection of degenerative facet joint disease.

Mitochondrial specialization revealed by single muscle fiber proteomics: focus on the Krebs cycle

We have developed a highly sensitive mass spectrometry-based proteomic workflow to examine the proteome of single muscle fibers. This study revealed significant differences in the mitochondrial proteome of the four major fiber types present in mouse skeletal muscle. Here, we focus on Krebs cycle enzymes and in particular on the differential distribution of the two mitochondrial isocitrate dehydrogenases, IDH2 and IDH3. Type 1/slow fibers contain high levels of IDH2 and relatively low levels of IDH3, whereas fast 2X and 2B fibers show an opposite expression pattern. The findings suggest that in skeletal muscle, IDH2 functions in the forward direction of the Krebs cycle and that substrate flux along the cycle occurs predominantly via IDH2 in type 1 fibers and via IDH3 in 2X and 2B fibers. IDH2-mediated conversion of isocitrate to α-ketoglutarate leads to the generation of NADPH, which is critical to buffering the H2O2 produced by the respiratory chain. Nicotinamide nucleotide transhydrogenase (NNT), the other major mitochondrial enzyme involved in NADPH generation, is also more abundant in type 1 fibers. We suggest that the continuously active type 1 fibers are endowed with a more efficient H2O2 scavenging capacity to cope with the higher levels of reactive oxygen species production.

Role of satellite cells in muscle growth and maintenance of muscle mass

Changes in muscle mass may result from changes in protein turnover, reflecting the balance between protein synthesis and protein degradation, and changes in cell turnover, reflecting the balance between myonuclear accretion and myonuclear loss. Myonuclear accretion, i.e. increase in the number of myonuclei within the muscle fibers, takes place via proliferation and fusion of satellite cells, myogenic stem cells associated to skeletal muscle fibers and involved in muscle regeneration. In developing muscle, satellite cells undergo extensive proliferation and most of them fuse with myofibers, thus contributing to the increase in myonuclei during early postnatal stages. A similar process is induced in adult skeletal muscle by functional overload and exercise. In contrast, satellite cells and myonuclei may undergo apoptosis during muscle atrophy, although it is debated whether myonuclear loss occurs in atrophying muscle. An increase in myofiber size can also occur by changes in protein turnover without satellite cell activation, e.g. in late phases of postnatal development or in some models of muscle hypertrophy. The relative role of protein turnover and cell turnover in muscle adaptation and in the establishment of functional muscle hypertrophy remains to be established. The identification of the signaling pathways mediating satellite cell activation may provide therapeutic targets for combating muscle wasting in a variety of pathological conditions, including cancer cachexia, renal and cardiac failure, neuromuscular diseases, as well as aging sarcopenia.