The role of magnetic resonance imaging in the diagnostic work-out of myopathies: differential diagnosis between inflammatory myopathies and muscular dystrophies

OBJECTIVES

The differential diagnosis between idiopathic inflammatory myopathies (IIM) and muscular dystrophies (MD) may be challenging. We analysed the potential role of muscular magnetic resonance imaging (MRI) in the differential diagnosis between IIM and MD.

METHODS

MRI of patients (91 IIM and 43 MD), studied with a standardised protocol, have been collected. The presence of oedema, muscular atrophy and intramuscular adipose changes were evaluated. Moreover, we computed a composite score for each MRI item to better discriminate between the two diseases.

RESULTS

Oedema was significantly more prevalent in IIM compared with MD in pelvis muscles (p<0.001), anterior lodge and medial lodges (p=0.044) of the thighs. Adipose infiltration/substitution and muscular atrophy were more prevalent in MD, in particular adipose tissue was prevalent in all the compartments of the thighs (p<0.05), atrophy was prevalent at the thighs and pelvis muscles (p<0.001). The probability of IIM increased with higher oedema score and decreased with higher atrophy and intramuscular adipose infiltration/substitution scores.

CONCLUSIONS

A different distribution of muscular involvement between IIM and MD has been identified. Muscular MRI may be useful in the differential diagnosis, potentially reducing the number of muscular biopsies that may be reserved only for doubtful cases.

Response assessment of locally advanced rectal cancer after neoadjuvant chemoradiotherapy: Is apparent diffusion coefficient useful on 3 T magnetic resonance imaging?

AIM

To assess the diagnostic value of apparent diffusion coefficient (ADC) on 3 T device for the prediction of tumoral response to neoadjuvant chemoradiotherapy (nCRT) and for the response assessment after nCRT in patients with locally advanced rectal cancer (LARC), using pathology as a reference.

METHODS

Forty-one patients affected by LARC undergoing 3.0 T MRI before and after nCRT were retrospectively selected. After the conventional acquisition of high resolution T2-weighted sequences, diffusion-weighted MRI (DW-MRI) was performed using a spin-echo echo-planar sequence with multiple b values (150, 500, 1000, 1500 s/mm² ). Fitted ADC values were calculated for each rectal lesion before and after nCRT by drawing a hand-made region of interest (ROI) around the tumour outline. All patients underwent surgery and pathological staging (classified according to tumour regression grading [TRG] and to tumour and node [TN]) represented the reference standard. Pretreatment ADC value (pre-ADC), ADC value obtained after nCRT (post-ADC) and the difference between post-ADC and pre-ADC (ΔADC) were correlated with both the TRG classes and the TN staging system in each patient.

RESULTS

The ADC values obtained in the post nCRT examination and the ΔADC were statistically related both to TRG (p = 0.0004; p = 0.0126, respectively) and TN (p = 0.0484; p = 0.0673, respectively) stages at histopathology. On the contrary, the pre-ADC was not related either to the TRG classes or to the lesion TN staging system (p > 0.05).

CONCLUSIONS

3 T DW-MRI using ADC value can be useful to assess the efficacy of nCRT in LARC; in fact, post-ADC and ΔADC values improve MR capability to evaluate tumour response.

Contextualizing bilateral asymmetry and gender: A multivariate approach to femoral cross-sectional geometry at rural Medieval Pieve di Pava, Italy

OBJECTIVES

Our objective was to identify the relationship between biocultural factors of sex-gender and age and patterns of femoral cross-sectional geometry with historical evidence about labor and activity from an archeological skeletal sample excavated from the rural Medieval site Pieve di Pava.

MATERIALS AND METHODS

The study site, Pieve di Pava, was a rural parish cemetery in Tuscany with osteoarcheological remains from the 7th to 12th centuries. Cross-sectional geometric analysis of femora from 110 individuals dated to the 10th-12th centuries were used to examine trends in bone quantity, shape, and bending strength between age and sex groups, as well as in clusters identified through Hierarchical Cluster Analysis (HCA).

RESULTS

Overall, our study sample showed remarkable heterogeneity and our cluster analysis revealed a complex underlying structure, indicating that divisions of labor did not follow a strict gender binary in our sample. We found high levels of bilateral asymmetry in our sample in multiple cross-sectional areas for a significant proportion of the population. We found minimal differences between age groups or sex.

DISCUSSION

Our results suggest that males and females had varied experiences of labor and work during their lives that did not reflect the strict binary gender roles sometimes documented for medieval Europe. One important axis of difference is the direction and magnitude of bilateral asymmetry observed in our femur sample, which is associated with divergent trends in section moduli and bone area measures.

Comparative structural analysis of polyurethane and silicone catheters of totally implantable venous access devices by micro-computed tomography

Objectives:

To investigate microstructural alterations of explanted long-term central venous catheters of totally implantable venous access devices, using micro-computed tomography.

Methods:

A total of 16 catheters (9 made of silicone and 7 made of polyurethane), all non-fractured, have been analyzed in this study. Eight catheters were implanted for an average duration of 994 days (min–max: 98–2731 days), while the remaining eight catheters (four for each material, forming the SIref and PUref control groups) were analyzed before implant and used as a reference. X-ray micro-computed tomography was used to reconstruct the three-dimensional geometry of selected segments of each catheter (ca. 10 cm per sample).

Results:

Morphometric analysis of the catheters revealed increases wall thickness and section area in the polyurethane group as compared with the reference central venous catheters of the same materials (wall thickness: 403 ± 12 μm in the polyurethane (PU) group vs 382 ± 4 μm in PUref, p = 0.014; wall cross-section area: 2.04 ± 0.09 mm² in PU vs 1.91 ± 0.03 mm² in PUref, p = 0.04), whereas implanted silicone catheters showed a larger luminal cross section as compared with their controls (lumen cross-section area = 0.851 ± 0.020 mm² in silicone (SI) group vs 0.811 ± 0.007 mm² in SIref, p = 0.007). All analyzed samples in this study presented some type of alteration in the catheter walls, namely, hyperdense spots (below 0.1 mm size), air gaps/bubbles and displacements of inner and outer axes causing heterogeneous wall thickness. The incidence of air gaps showed no difference with respect to both material type and duration of implant, whereas the SI group revealed more hyperdense spots as compared to all other groups.

Conclusion:

Morphological change and local structural alteration can occur in both silicone and polyurethane catheters. This evidence suggests the need for further studies connecting those morphological changes with modification of mechanical robustness, which ultimately can play a role for patient safety.

Echoentomography for Assessing Braconid Parasitization on Soft-Bodied Tephritid Hosts

Entomological approaches currently available for assessing host parasitization require dissection, polymerase chain reaction (PCR), or waiting for adult emergence. The first two methods are relatively fast but destructive, whereas the third one allows the emergence of the parasitoid but it is time consuming. In this framework, new diagnostic imaging tools may contribute to solve the lack of an accurate, rapid, and non-invasive approach to evaluate the parasitization of soft-bodied insects by their endoparasitoids. In this study, ultra-high frequency ultrasound (UHFUS) technology, which is currently used in medical and preclinical fields, was adopted to assess the parasitization of the invasive polyphagous Mediterranean fruit fly, Ceratitis capitata (Diptera: Tephritidae), testing 2nd and 3rd instar larvae. Parasitization assays were carried out with the solitary koinobiont endophagous parasitoid Psyttalia concolor (Hymenoptera: Braconidae: Opiinae). The efficacy of UHFUS-based echoentomography was compared with the classical method of dissecting the larval host under a stereomicroscope. Our results showed that the UHFUS diagnostic capability was statistically comparable with that of dissection, both on C. capitata 2nd and 3rd larvae. Overall, UHFUS-based echoentomography may be further considered as a fast, non-invasive, and effective approach to evaluate the parasitoid's ability to successfully oviposit in soft-bodied hosts.

Patient Perceptions and Knowledge of Ionizing Radiation From Medical Imaging

IMPORTANCE

Although imaging has become a standard tool of modern medicine, its widespread use has been paralleled by an increasing cumulative radiation dose to patients despite technological advancements and campaigns calling for better awareness and minimization of unnecessary exposures.

OBJECTIVE

To assess patients' knowledge about medical radiation and related risks.

DESIGN, SETTING, AND PARTICIPANTS

A survey study of hospitals in Italy was conducted; all patients in waiting rooms for medical imaging procedures before undergoing imaging examinations at 16 teaching and nonteaching hospitals were approached to take the survey. The survey was performed from June 1, 2019, to May 31, 2020.

MAIN OUTCOMES AND MEASURES

Survey respondents' basic knowledge of ionizing radiation levels and health risks, earlier imaging tests performed, and information and communication about radiation protection issues.

RESULTS

Among 3039 patients invited to participate, the response rate was 94.3% (n = 2866). Participants included 1531 women (53.4%); mean (SD) age was 44.9 (17.3) years. Of the 2866 participants, 1529 (53.3%) were aware of the existence of natural sources of ionizing radiation. Mammography (1101 [38.4%]) and magnetic resonance imaging (1231 [43.0%]) were categorized as radiation-based imaging modalities. More than half of the 2866 patients (1579 [55.1%]; P = .03) did not know that chest computed tomography delivers a larger dose of radiation than chest radiography, and only 1499 (52.3%) knew that radiation can be emitted after nuclear medicine examinations (P = .004). A total of 667 patients (23.3%) believed that radiation risks were unrelated to age, 1273 (44.4%) deemed their knowledge about radiation risks inadequate, and 2305 (80.4%) preferred to be informed about radiation risks by medical staff. A better knowledge of radiation issues was associated with receiving information from health care professionals (odds ratio [OR], 1.71; 95% CI, 1.43-2.03; P < .001) and having a higher educational level (intermediate vs low: OR, 1.48; 95% CI, 1.17-1.88; P < .001; high vs low: OR, 2.68; 95% CI, 2.09-3.43; P < .001).

CONCLUSIONS AND RELEVANCE

The results of this survey suggest that patients undergoing medical imaging procedures have overall limited knowledge about medical radiation. Intervention to achieve better patient awareness of radiation risks related to medical exposures may be beneficial.

POS0778 ULTRA HIGH-RESOLUTION ULTRASOUND (UHFUS) OF LABIAL GLANDS IS A STRONG PREDICTOR OF SALIVARY GLAND HISTOPATHOLOGY IN SJÖGREN’S SYNDROME (PSS)

Background:

Last-generation ultra high-resolution ultrasound (UHFUS) transducers, producing frequencies up to 70 MHz and achieving tissue resolution up to 30 μm, are opening up new possibilities for the study of labial salivary glands (LSG) in patients clinically suspected with primary Sjögren’s syndrome (pSS).

Objectives:

To explore the value of LSG-UHFUS as a predictor of the intensity of the histological inflammation in LSG biopsy in an inception cohort of patients with sicca symptoms derived from daily clinical practice.

Methods:

Consecutive patients undergoing a LSG for clinically suspected pSS were included in this study from January 2018 to October 2020. UHFUS of LSG was performed by using VEVO MD, equipped with a 70 MHz probe, scanning first the central compartment of the inferior lip, and then both peripheral compartments. Parenchymal homogeneity was graded on a scale of 0 (normal) to 3 (evident). UHFUS imaging was used to locate the LSG for the US-guided biopsy. For each of the LSG specimens the area of the glandular tissue, the presence and number of foci and the focus score (FS) were assessed. Immunostaining for CD21 was performed to evaluate the presence of follicular dendritic cells (FDC) in foci.

Results:

We included a total of 171 patients with suspected pSS: out of them, 83 (48.5%) received a diagnosis of pSS (ACR 2016 criteria) and 88 (51.5 %) were diagnosed as no-SS sicca controls. Out of the 171 LSG biopsies, 73/171 (42.7%) were characterized by a nonspecific chronic sialadenitis (NSCS) whereas a focal lymphocytic sialadenitis (FLS) was described in the remaining 98/171 (57.3%). UHFUS-LSG scores were differently distributed in pSS patients with respect to no-SS sicca controls: a score 0 was detected in 16/88 no-SS sicca controls and in none of the 83 pSS patients, whereas a score 3 was detected in 12/83 pSS and in none of no-SS sicca controls. (p<0.001). The higher was the UHFUS grading, the higher was the number of foci (from a mean (S.D) = 0.38 (0.72) in UHFUS-score 0 to 4.58 (3.11) in UHFUS-score 3, p<0.001) and the focus score (from 0.17 (0.32) in UHFUS-score 0 to 1.88 (0.90) in UHFUS-score 3, p<0.001) of the samples. Overall, out of the 16 no-SS controls with LSG-UHFUS score 0, only 4/16 showed histological features of focal lymphocytic infiltrate; however, the mean FS of those 4/16 samples was 0.17 (0.32). In fact, considering a FS≥1, negative UHFUS-LSG was highly predictive of a negative histology (100 %). By contrast, out of the 12 pSS patients with the highest score at LSG-UHFUS (score 3), 10/12 presented FDC networks in their biopsies, with a positive predictive value of 83% of the severity of the infiltrate.

Conclusion:

UHFUS of LSG appeared feasible and sensitive in pSS; due to its striking negative predictive value this novel tool can help to identify negative patients on subsequent lip biopsy, thus avoiding invasive procedures in selected cases. Besides its diagnostic role, considering the association with the presence of FDC networks, UHFUS-LGS may also have a role in patients prognostic stratification.

Disclosure of Interests:

None declared

Humeral greater tuberosity osteolysis as a complication of intraosseous calcification migration: natural history depicted by imaging

Migration of calcification within the bone leading to greater tuberosity osteolysis is a peculiar complication of the calcifying tendinitis of the rotator cuff. The case of a 38-year-old woman complaining of right shoulder pain, which had been going on for one year, is hereby described. The evolution of the infraspinatus tendon calcifying tendinitis leading to osteolysis of the greater tuberosity of the humerus is depicted by imaging and, particularly, by the MR and CT features changing over time. In this paper we focus on the importance of both MR and CT exams in the diagnostic process of the different phases of the disease. The correlation between clinical symptoms and imaging features is also helpful for imaging interpretation: the most painful phase corresponds to the migration of the calcification, whereas pain tends to decrease when the osteolysis develops. Awareness of the existence of this condition may prevent unnecessary invasive procedures.

Post-mortem CMR in a model of sudden death due to myocardial ischemia: validation with connexin-43

OBJECTIVES

We sought to evaluate the effectiveness of post-mortem cardiac magnetic resonance (PM-CMR) for the identification of myocardial ischemia as cause of sudden cardiac death (SCD) when the time interval between the onset of ischemia and SCD is ≤ 90 min.

METHODS

PM-CMR was performed in 8 hearts explanted from pigs with spontaneous death caused by occlusion of the left anterior descending coronary artery: 4 with SCD after ≤ 40 min of coronary occlusion and 4 between 40 and 90 min. PM-CMR included conventional T1 and T2-weighted image and T1, T2, and T2* mapping techniques. Imaging data were compared and validated with immunohistochemical evaluation of the altered proportion and redistribution of phosphorylated versus non-phosphorylated connexin 43 (CX43 and npCX43, respectively), an established molecular marker of myocardial ischemia.

RESULTS

At T2-weighted images, the ischemic core was hypointense (core/remote ratio 0.67 ± 0.11) and surrounded by and hyperintense border zone. Compared to remote myocardium, the ischemic core had higher T1 (p = 0.0008), and lower T2 (p = 0.007) and T2* (p = 0.002). Cytoplasmatic npX43 and the npCX43/CX43 ratio were significantly higher in animals deceased > 40 min than in others.

CONCLUSION

PM-CMR can reliably detect early signs of myocardial damage induced by ischemia, based on conventional pulse sequences complemented by a novel ad hoc application of quantitative mapping techniques.

KEY POINTS

• Post-mortem MRI may help to understand cause of sudden cardiac death. • Post-mortem MRI allows detection of signs of myocardial ischemia as cause of sudden cardiac death within 90 and 40 min following coronary occlusion as demonstrated in a pig model of myocardial ischemia. • Signs of myocardial ischemia using conventional and mapping MRI technique are associated with the immunohistochemical changes of phosphorylated and dephosphorylated connexin-43 which is an established molecular marker of myocardial ischemia.

Ultra-high frequency ultrasonography (UHFUS)-guided minor salivary gland biopsy: A promising procedure to optimize labial salivary gland biopsy in Sjögren's syndrome

BACKGROUND

Sjögren's syndrome (SS) is an autoimmune disease characterized by an inflammatory infiltrate of exocrine salivary and lachrymal glands. Diagnosis is complex, and minor salivary gland biopsy and subsequent focus score (FS) calculation appear of extreme importance in the diagnostic work-up of the disease. Ultra-high frequency ultrasonography (UHFUS) is a recently introduced diagnostic technique, which is gaining an increasingly important role in intraoral imaging. This study aims at exploring the usefulness of UHFUS for obtaining valuable labial salivary gland samples to assess the histopathological features of SS patients.

METHODS

Patients with clinical suspect of SS and eligible for minor salivary gland biopsy were enrolled. UHFUS scan of the lower lip was performed. Glandular echostructure was classified according to Outcome Measures in Rheumatology (OMERACT) scoring system. The glands to be sampled were selected on the basis of UHFUS evaluation and biopsied. The areas of the samples were recorded and compared with those obtained without UHFUS guidance. The correlation between UHFUS grade and labial gland FS was also assessed.

RESULTS

The areas of the samples obtained with UHFUS guidance were significantly higher (7.25 ± 3.98 mm² ) than those obtained by conventional procedures (5.79 ± 3.49 mm² , P = .02). UHFUS correlated significantly with the salivary gland FS (r = .532, P = .001).

CONCLUSION

UHFUS seems a promising tool in SS diagnostic algorithm, being able to provide a valuable support to the biopsy procedure. Further studies are mandatory to confirm the role of UHFUS in SS.

A comprehensive assessment of physical image quality of five different scanners for head CT imaging as clinically used at a single hospital centre-A phantom study

Nowadays, given the technological advance in CT imaging and increasing heterogeneity in characteristics of CT scanners, a number of CT scanners with different manufacturers/technologies are often installed in a hospital centre and used by various departments. In this phantom study, a comprehensive assessment of image quality of 5 scanners (from 3 manufacturers and with different models) for head CT imaging, as clinically used at a single hospital centre, was hence carried out. Helical and/or sequential acquisitions of the Catphan-504 phantom were performed, using the scanning protocols (CTDI_vol range: 54.7–57.5 mGy) employed by the staff of various Radiology/Neuroradiology departments of our institution for routine head examinations. CT image quality for each scanner/acquisition protocol was assessed through noise level, noise power spectrum (NPS), contrast-to-noise ratio (CNR), modulation transfer function (MTF), low contrast detectability (LCD) and non-uniformity index analyses. Noise values ranged from 3.5 HU to 5.7 HU across scanners/acquisition protocols. NPS curves differed in terms of peak position (range: 0.21–0.30 mm^-1). A substantial variation of CNR values with scanner/acquisition protocol was observed for different contrast inserts. The coefficient of variation (standard deviation divided by mean value) of CNR values across scanners/acquisition protocols was 18.3%, 31.4%, 34.2%, 30.4% and 30% for teflon, delrin, LDPE, polystyrene and acrylic insert, respectively. An appreciable difference in MTF curves across scanners/acquisition protocols was revealed, with a coefficient of variation of f_50%/f_10% of MTF curves across scanners/acquisition protocols of 10.1%/7.4%. A relevant difference in LCD performance of different scanners/acquisition protocols was found. The range of contrast threshold for a typical object size of 3 mm was 3.7–5.8 HU. Moreover, appreciable differences in terms of NUI values (range: 4.1%-8.3%) were found. The analysis of several quality indices showed a non-negligible variability in head CT imaging capabilities across different scanners/acquisition protocols. This highlights the importance of a physical in-depth characterization of image quality for each CT scanner as clinically used, in order to optimize CT imaging procedures.

Ultra-high frequency ultrasound in the differential diagnosis of oral pemphigus and pemphigoid: An explorative study

OBJECTIVES

Intraoral ultra-high frequency ultrasound (UHFUS) is an emerging technique in oral medicine, due to its possibility to provide submillimeter resolution imaging of superficial mucosal structures. In this study, the potential role of UHFUS in the diagnosis of oral pemphigus vulgaris (PV) and mucous membrane pemphigoid (MMP) is assessed.

MATERIALS AND METHODS

Consecutive patients with suspected oral PV or MMP were enrolled. All patients underwent clinical examination, laboratory tests, intraoral UHFUS scan, and biopsy. Histology and direct immunofluorescence were set as benchmark for diagnosis confirmation. The sensitivity and specificity of UHFUS compared to histology were assessed. Mann-Whitney test was performed to evaluate the presence of differences in the echogenicity of PV and MMP. P-value was set at P < 0.05.

RESULTS

Twenty-five patients were included. Thirteen patients were diagnosed with PV, and twelve with MMP. The UHFUS features of PV and MMP lesions were described. Image analysis showed statistically significant differences between the echogenicity of PV and MMP lesions (P < 0.05). Good concordance between UHFUS and histology was found. UHFUS showed 75% sensitivity in the diagnosis of PV and 66.7% in the diagnosis of MMP.

CONCLUSIONS

UHFUS appears a valuable tool in the diagnosis of PV and MMP. Although histology and immunofluorescence remain the gold standard, UHFUS role in the diagnostic algorithm of PV and MMP seems promising as a chair-side tool consistently enhancing clinical evaluation of oral bullous lesions.

Cardiac Computed Tomography Perfusion: Contrast Agents, Challenges and Emerging Methodologies from Preclinical Research to the Clinics

Computed Tomography (CT) has long been regarded as a purely anatomical imaging modality. Recent advances on CT technology and Contrast Agents (CA) in both clinical and preclinical cardiac imaging offer opportunities for the use of CT in functional imaging. Combined with modern ECG-gating techniques, functional CT has now become a reality allowing a comprehensive evaluation of myocardial global and regional function, perfusion and coronary angiography. This article aims at reviewing the current status of cardiac CT perfusion and micro-CT perfusion with established and experimental scanners and contrast agents, from clinical practice to the experimental domain of investigations based on animal models of heart diseases.

Ultra-high frequency ultrasound (UHFUS) applications in Sjogren syndrome: narrative review and current concepts

Primary Sjogren's syndrome (SS) is a systemic autoimmune chronic inflammatory disease with predominant involvement of the exocrine glands, particularly the salivary glands (SGs). The role of salivary glands ultrasound (SGUS) in the work-up of patients with primary Sjogren syndrome (SS) is progressively increasing due to its useful support in diagnosis and follow-up as a widely available, repeatable, non-invasive and safe technique. Although SGUS is not yet included in the dominant primary SS classification, several studies supported its inclusion in the American College of Rheumatology/European League Against Rheumatism criteria. In this context, a novel imaging technique, ultra-high frequency ultrasound (UHFUS), is being explored. Compared to the frequencies used in conventional ultrasound (US) (up to 22 MHz), UHFUS operates with higher frequencies (30-100 MHz) allowing for outstanding image resolution, up to 30 µm. UHFUS permits the scan of both major and minor SGs, opening new avenues for the integration of tissue and imaging biomarkers. Although further studies are needed to confirm its role, this novel imaging technique might lead to several potential improvements, including earlier diagnosis, reduction of unnecessary and inadequate biopsies and better management and follow-up of patients with primary SS.

Technical evaluation of image quality in synthetic mammograms obtained from 15° and 40° digital breast tomosynthesis in a commercial system: a quantitative comparison

Digital breast tomosynthesis (DBT) has recently gained interest both for breast cancer screening and diagnosis. Its employment has increased also in conjunction with digital mammography (DM), to improve cancer detection and reduce false positive recall rate. Synthetic mammograms (SMs) reconstructed from DBT data have been introduced to replace DM in the DBT + DM approach, for preserving the benefits of the dual-acquisition modality whilst reducing radiation dose and compression time. Therefore, different DBT models have been commercialized and the effective potential of each system has been investigated. In particular, wide-angle DBT was shown to provide better depth resolution than narrow-angle DBT, while narrow-angle DBT allows better identification of microcalcifications compared to wide-angle DBT. Given the increasing employment of SMs as supplement to DBT, a comparison of image quality between SMs obtained in narrow-angle and wide-angle DBT is of practical interest. Therefore, the aim of this phantom study was to evaluate and compare the image quality of SMs reconstructed from 15° (SM₁₅) and 40° (SM₄₀) DBT in a commercial system. Spatial resolution, noise and contrast properties were evaluated through the modulation transfer function (MTF), noise power spectrum, maps of signal-to-noise ratio (SNR), image contrast, contrast-to-noise ratio (CNR) and contrast-detail (CD) thresholds. SM₄₀ expressed higher MTF than SM₁₅, but also lower SNR and CNR levels. SM₁₅ and SM₄₀ were characterized by slight different texture, and a different behavior in terms of contrast was found. SM₁₅ provided better CD performances than SM₄₀. These results suggest that the employment of wide/narrow-angle DBT + SM images should be optimized based on the specific image task.

Cone-Beam Computed Tomography vs. Multi-Slice Computed Tomography in paleoimaging: where we stand

Paleopathology and anthropology are fields of research which have benefited from the use of diagnostic imaging since its introduction in the clinical setting. The deriving discipline, that is, paleoimaging, has effectively employed several diagnostic techniques. However, while Multi-Slice Computed Tomography (MSCT) has found its role in paleoimaging, Cone-Beam Computed Tomography (CBCT), despite its several advantages with regard to MSCT, is still struggling to find a clear position in this field. The aim of our study is to evaluate the possible advantages CBCT could bring to paleoimaging. We describe the characteristics and role of CBCT in clinical applications, in forensic and legal medicine, and in paleopathology. We report the study of an ancient mandible by means of CBCT and MSCT, in order to compare the quality of the images in terms of spatial resolution. CBCT allows to obtain good quality images of mineralized tissues. Moreover, the possibility of imaging metallic manufacts makes the technique suitable for the study not only of bony remains, but also of museum and archaeological artifacts. Our study highlights the strengths of CBCT as a valid imaging technique for the study of ancient bone remains and manufacts. A revision of the current uses of CBCT is provided and gives insights into the possible role it can cover in bioarchaeological studies. Further evaluation is needed in terms of possible applications of this technique to paleopathology. We strongly encourage the use of CBCT in paleoimaging, and suggest a broader application of the technique to the study of archaeological samples.

Side-branch intraductal papillary mucinous neoplasms of the pancreas: outcome of MR imaging surveillance over a 10 years follow-up

Purpose

To evaluate the outcome of a MR imaging procotol in assessing the evolution of individuals with branch duct - intraductal papillary mucinous neoplasms (BD-IPMN) without worrisome features (WF) and/or high risk stigmata (HRS) at the time of the diagnosis in a follow-up period of at least 10 years.

Material and methods

A retrospective revision of a prospectively collected radiological database including a total number of 600 patients who were investigated and diagnosed with "presumed" diagnosis of BD-IPMN at MRI/MRCP at our Department since 2008 was performed. Inclusion criteria were: 1) absence of worrisome features and/or high-risk stigmata at the time of diagnosis (baseline); 2) a radiological follow-up with abdominal MRI/MRCP of at least 10 years. Changes in cysts size, development of WF, HRS and pancreatic cancer, and any other modification during the follow-up were retrospectively analysed by two observers in consensus.

Results

Sixty-nine patients fulfilled all the inclusion criteria. During surveillance, the cysts remained dimensionally unchanged or slightly reduced in size in 26.2% and 4.3% of cases respectively, whereas cyst enlargement was demonstrated in 69.5% of cases. Median annual growth rate was of 0.97 ± 0.87 mm/yr (range 0.13-5.0). WF and HRS developed in 10/69 (14.5%) and 3/69 (4.3%) cases, respectively. The incidence of pancreatic cancer in patients with BD-IPMN was 2.9%.

Conclusion

Our data confirm the low risk of pancreatic cancer development in patients with BD-IPMN, thus justifying an imaging follow-up. Worrisome features and high-risk stigmata were promptly identified during the follow-up, supporting the utility of our surveillance MR imaging protocol.

Ultra-High Frequency Ultrasound, A Promising Diagnostic Technique: Review of the Literature and Single-Center Experience

OBJECTIVES

Ultra-high frequency ultrasonography (UHFUS) is a recently introduced diagnostic technique which finds several applications in diverse clinical fields. The range of frequencies between 30 and 100 MHz allows for high spatial resolution imaging of superficial structures, making this technique suitable for the imaging of skin, blood vessels, musculoskeletal anatomy, oral mucosa, and small parts. However, the current clinical applications of UHFUS have never been analyzed in a consistent multidisciplinary manner. The aim of this study is to revise and discuss the current applications of UHFUS in different aspects of research and clinical practice, as well as to provide some examples of the current work-in-progress carried out in our center.

MATERIALS AND METHODS

A literature search was performed in order to retrieve articles reporting the applications of UHFUS both in research and in clinical settings. Inclusion criteria were the use of frequencies above 30 MHz and study design conducted in vivo on human subjects.

RESULTS

In total 66 articles were retrieved. The majority of the articles focused on dermatological and vascular applications, although musculoskeletal and intraoral applications are emerging fields of use. We also describe our experience in the use of UHFUS as a valuable diagnostic support in the fields of dermatology, rheumatology, oral medicine, and musculoskeletal anatomy.

CONCLUSION

Ultra-high frequency ultrasonography application involves an increasing number of medical fields. The high spatial resolution and the superb image quality achievable allow to foresee a wider use of this novel technique, which has the potential to bring innovation in diagnostic imaging.

Average absorbed breast dose (2ABD): an easy radiation dose index for digital breast tomosynthesis

Background

To propose a practical and simple method to individually evaluate the average absorbed dose for digital breast tomosynthesis.

Methods

The method is based on the estimate of incident air kerma (k_a,i) on the breast surface. An analytical model was developed to calculate the k_a,i from the tube voltage, tube load, breast thickness, x-ray tube yield, and anode-filter combination. A homogeneous phantom was employed to simulate the breast in experimental measurements and to assess the dose-depth relationship. The k_a,i values were employed to calculate the “average absorbed breast dose” (2ABD) index. Four mammographic units were used to develop and test our method under many conditions close to clinical settings. The average glandular dose (AGD) calculated following the method described by Dance et al., and the 2ABD computed through our method (i.e., from the exposure parameters) were compared in a number of conditions.

Results

A good agreement was obtained between the k_a,i computed through our model and that measured under different clinical conditions: discrepancies < 6% were found in all conditions. 2ABD matches with a good accuracy the AGD for a 100% glandular-breast: the minimum, maximum, and mean differences were < 0.1%, 7%, and 2.4%, respectively; the discrepancies increase with decreasing breast glandularity.

Conclusions

The proposed model, based on only few exposure parameters, represents a simple way to individually calculate an index, 2ABD, which can be interpreted as the average absorbed dose in a homogeneous phantom, approximating a 100% glandular breast. The method could be easily implemented in any mammographic device performing DBT.

Ultra-high frequency ultrasonography of labial glands is a highly sensitive tool for the diagnosis of Sjögren's syndrome: a preliminary study

OBJECTIVES

Ultra-high frequency ultrasonography (UHFUS) has been recently introduced in oral medicine due to its ability to image small anatomical structures including labial salivary glands (LSG). To date no ultrasonography morphological studies of labial salivary glands (LSG) have been carried out in SS. In this pilot study we aimed at analysing the distribution of UHFUS findings in LSG of patients with suspected SS, focusing in particular on the association with patients' oral dysfunction, antibody profiles and histopathology.

METHODS

Consecutive patients undergoing a LSG biopsy for clinically suspected SS were included in this study between January 2018 and January 2020. Intraoral UHFUS scan of the lip mucosa was performed with Vevo MD equipment, using a 70 MHz probe with a standardised protocol. LSG were assessed by using a four-grade semiquantitative scoring system (0-3), similar to the OMERACT scoring system used for major salivary glands. The distribution of UHFUS grades was compared in patients stratified according their final diagnosis, patients antibody profiles and LSG histopathology.

RESULTS

We included 128 patients with suspected SS: out of them, 54 (42.2%) received a final diagnosis of SS, made according to the ACR 2016 criteria and 74 (57.8%) were diagnosed as no-SS sicca controls. We found that LSG inhomogeneity was significantly greater in patients with SS than in no-SS subjects (p<0.0001). We also found that higher UHFUS pattern of inhomogeneity (i.e. grade 2 and 3) were significantly more frequent in both SSA+/SSB- and SSA+/SSB+ patients (p=0.001). A normal UHFUS pattern, by contrast, was significantly more common in SSA-/SSB- subjects (i.e. 15/83 (18.1%) vs. 1/33 (3%) vs. 0/12 (0%), p=0.001). Finally, LSG inhomogeneity was significantly associated with both the number of foci (p<0.001) and focus score (p<0.001). Particularly, we found that both the number of foci and the FS were significantly higher in patients presenting a UHFUS grading of 2 and 3 with respect to those presenting a UHFUS grading of 0 and 1 (p=0.01).

CONCLUSIONS

This preliminary study demonstrates the optimal feasibility of UHFUS and its high sensitivity in identifying negative patients on subsequent lip biopsy, thus avoiding invasive procedures in selected cases. Further studies are in progress to define the clinical and predictive role of the various patterns observed and their added value with respect to traditional salivary gland ultrasonography.

SAT0306 SEMIQUANTITATIVE AND QUANTITATIVE ANALYSIS OF LUNG CT IN THE ASSESSMENT OF INTERSTITIAL LUNG DISEASE IN IDIOPATHIC INFLAMMATORY MYOPATHIES WITH A FOCUS ON ANTISYNTHETASE

Background:

Interstitial lung disease (ILD), is common in patients with idiopathic inflammatory myopathies (IIM) and strongly impact on patients’ morbidity and mortality. Patients with anti-aminoacyl-transfer RNA-synthetases (anti-ARS) antibodies are associated with an increased risk of ILD.

Objectives:

Defining the radiological characteristics of IIM patients, with special focus on serological groups, through qualitative, semiquantitative and quantitative analysis of lung CT.

Methods:

This was a prospective study conducted from 2016 to 2019. Ninety-eight IIM patients (35 men, 63 women) were included. Myositis specific autoantibodies (MSA) were assessed with Myositis Prophyle III (Euroimmune, Lubeck).

Each patient had a baseline CT; the total score of Warrick (WS) was obtained at semiquantitative analysis. The radiological scores ILD% (interstitial lung disease %) and PVRS% (pulmonary vascular related structure) were the result of quantitative analysis in 61 patients (CALIPER). Pulmonary function tests (PFTs) included TLC%, FVC% and DLCO% (65 patients). The analysis was conducted in the whole group and divided in subgroups based on their MSA pattern: in particular anti-ARS (Group 1) and patients negative to MSA (Group 2) were analysed.

Results:

Positive correlations between ILD% and PVRS% (Rho=0.916; ρ=0.000), WS and ILD% (Rho=0.663; ρ=0.000) and WS and PVRS% (Rho=0.637; ρ<0.001) were found.

The most relevant inverse correlations were found between ILD% and DLCO% (Rho=-0.590; ρ=0.001), PVRS% and DLCO% (Rho=-0.549; ρ<0.001) and WS and DLCO% (Rho=-0.471; ρ<0.001).

Statistically significant higher values of WS, ILD% and PVRS% were found in Group 1 (WS=15, ILD%=11 and PVRS%=3.5), compared to Group 2 (WS=2.5, ILD%=0.84 and PVRS%=2.2). NSIP pattern resulted dominant represented in the two groups (80% Group 1, 75% Group 2). No statistically significant differences of DLCO%, FVC% and TLCO% were found.

Conclusion:

The inverse correlations between the radiological scores and the functional data TLC% and DLCO% (ρ<0.001) confirm the role of lung CT in the clinical management of ILD in IIM patients, and may represent a promising tool for clinical trials. For the first time anti-ARS and serological negative patients were defined through qualitative, semiquantitative and quantitative analysis of lung CT. Further study should be conducted in order to define the prognostic value of the quantitative analysis of lung CT in the follow up of IIM patients.

Disclosure of Interests:

None declared

FRI0153 ULTRA HIGH-RESOLUTION ULTRASOUND (UHFUS) OF LABIAL SALIVARY GLANDS: POTENTIAL APPLICATIONS IN PRIMARY SJÖGREN’S SYNDROME

Background:

Major salivary gland ultrasonography has an established role in diagnosis and assessment of pSS. Nowadays, however, interest is also growing in last-generation ultra high resolution ultrasound (UHFUS) transducers, which can produce frequencies up to 70 MHz and achieve tissue resolution up to 30 μm, opening up new possibilities for the study labial salivary glands (LSG).

Objectives:

To investigate the usefulness of UHFUS in LSG ultrasound-guided biopsy and preoperative planning.

Methods:

Consecutive patients undergoing a LSG for clinically suspected pSS were included in this study from January 2018 to December 2019. UHFUS of LSG was performed by using VEVO MD, equipped with a 70 MHz probe, scanning first the central compartment of the inferior lip, and then both peripheral compartments. The following parameters were evaluated: distribution of the glands, parenchymal inhomogeneity (score 0-3, from normal to evident), and fibrosis. UHFUS imaging was used to help locate the LSG for the US-guided biopsy. The same expert pathologist calculated the surface area of gland sections examined, the LSG focus score (FS), the number of foci and evaluated the presence of ectopic germinal centers (GCs). Consecutive patients that had undergone a traditional LSG biopsy from December 2016 to December 2017 were included as controls.

Results:

We included a total of 249 patients with suspected pSS: 137 undergoing the UHFUS-guided LSGs and 112 the traditional LSG biopsy procedure. No demographic differences were observed between the two groups. No differences were also observed in the distribution of the final diagnosis. A diagnosis of pSS according the ACR 2016 criteria was made in 60/137 (43.8%) and 36/112 (32.1%) patients, respectively whereas a diagnosis of no-SS sicca was made in 44/137 (32.1%) and in 43/112 (38.4%) patients; the remaining diagnosis included secondary SS (4/137, 3% and 9/112, 8%) and undifferentiated connective tissue disease (UCTD) (29/137, 21.2%, and 24/112, 21.4%). With respect to no-SS sicca controls and UCTD patients, pSS patients presented higher UHFUS inhomogeneity scores in both central and peripheral labial compartments (p=0.001). There were no complications from the HUFUS-guided LSG biopsy. The mean glandular surface area obtained was significantly higher than the area obtained by traditional LSG biopsy procedure (7.4 ±4.0 mm2vs 6.3±3.7 mm2, p=0.02) thus facilitating the assessment of the FS. Interestingly, the latter showed a good correlation with the UHFUS inhomogeneity (r=0.509**, p=0.000).

Conclusion:

UHFUS of LSG appeared feasible and sensitive in pSS, potentially offering unique advantages in LSG ultrasound-guided biopsy.

Disclosure of Interests:

None declared

FRI0263 QUANTITATIVE MUSCLE ULTRASOUND IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES-A PRELIMINARY STUDY

Background:

Muscle involvement is the most frequent clinical feature in patients with idiopathic inflammatory myopathies (IIM). In addition to muscular enzymes, muscular magnetic resonance has been investigated for the assessment of disease activity, but it is limited by high costs and it is not readily available. Muscle ultrasound (MUS) has been recently proposed as a valuable tool for the diagnosis and activity assessment of muscle involvement in IIM patients.

Objectives:

To define the role of MUS in the diagnosis and assessment of disease activity in IIM through quantitative analysis of MUS

Methods:

This was a prospective study conducted from February 2019 to November 2019. 41 patients with IIM: 17 men and 24 women, median age 61.4 years, of which 20 were polymyositis (PM), 16 dermatomyositis (DM) and 5 inclusion body myositis (IBM) were included. 30 healthy subjects (HS), comparable in age and gender to patients, were recruited as controls. In every patient and control MUS of upper and lower extremities was performed (in total 10 muscles per side) and digital images were saved. Quantitative muscle echo intensity (QME) was calculated using an image processing program (ImageJ) to obtain the mean value of greyscale (mGS) for each muscle. For patients with IIM creatine phosphokinase (CPK) levels were recorded, duration of disease (in months) was calculated and clinical evaluation tools for the assessment of disease activity were performed, such as manual muscle testing (MMT8), patient and physician visual analogue scales (pVAS, phVAS), health assessment questionnaire (HAQ) and myositis disease activity assessment tool (MDAAT).

Results:

Patients had higher values of mGS across all muscles examined than controls (p<0.001). Among patients QME showed a negative correlation with MMT8 (p<0.001, -0.641<r<-0.412), but no correlation with CPK levels or duration of disease. A positive correlation was found between QME and HAQ (p<0.05; 0.320<r<0.599), pVAS (0.003<p<0.046; 0.314<r<0.455) and phVAS (0.029<p<0.002; 0.341<r<0.471). No significant correlation was found between QME and MDAAT and no statistically significant differences of muscle echo intensity were observed between patients with IBM, DM and PM.

Conclusion:

Quantitative analysis of MUS showed to be useful to differentiate IIM patients from healthy subjects, therefore it could be a helpful technique to screen patients with muscular symptoms in which perform additional investigations. In our study, the data collected did not allow to assess the disease activity of IIM patients and did not allow to distinguish between the 3 different subgroups of IIM patients, but further studies may help in the identification of different muscular patterns to guide the clinical suspect and the possible role of MUS in the follow-up of the patients.

Disclosure of Interests:

Alessandra Tripoli: None declared, Simone Barsotti: None declared, Andrea Delle Sedie Speakers bureau: MSD, Lilly, Novartis, Abbvie, Celgene, Giacomo Aringhieri: None declared, Saverio Vitali: None declared, Rossella Neri: None declared, Davide Caramella: None declared, Marta Mosca: None declared

Discovering a new anatomy: exploration of oral mucosa with ultra-high frequency ultrasound

OBJECTIVES

Ultra-high frequency ultrasound (UHFUS) is a recently developed diagnostic technique involving the use of ultrasound frequencies up to 70 MHz, allowing to obtain 30 µm resolution of targets located within 1 cm from the surface. Oral mucosa can be affected by diverse pathological conditions, which are currently investigated by means of clinical examination. In this scenario, intraoral UHFUS can provide additional information and support clinical assessment of oral mucosa. In this preliminary study, typical features of normal oral mucosa are described, in order to set a benchmark for the future identification of oral soft tissue alterations.

METHODS

Twenty healthy subjects (10 males and 10 females, mean age 30 years) were enrolled and underwent intraoral UHFUS examination. In all the subjects, tongue, buccal mucosa, gingiva, lip mucosa, and palate were scanned, and images acquired. Intraoral UHFUS scan included Brightness-mode and Doppler mode acquisitions performed with a standardized protocol. UHFUS images were postprocessed and analyzed using a dedicated software. UHFUS-based biomarkers (epithelial thickness, echogenicity, and vascularization) were employed for image description.

RESULTS

Normal oral anatomy of the different sites analyzed was described. For all the sites, UHFUS biomarkers were characterized, and information on typical aspect of oral mucosa was retrieved.

CONCLUSIONS

In this explorative study, we suggest a potential role for intraoral UHFUS in the study of oral mucosa, giving insights into the possibility to improve the assessment, diagnosis, and management of the conditions involving oral mucosa. UHFUS seems a promising tool, which could potentially support clinical examination in daily oral medicine practice.

Imaging of the vulnerable carotid plaque: Role of imaging techniques and a research agenda

OBJECTIVES

Atherothrombosis in the carotid arteries is a main cause of ischemic stroke and may depend on plaque propensity to complicate with rupture or erosion, in turn related to vulnerability features amenable to in vivo imaging. This would provide an opportunity for risk stratification and-potentially-local treatment of more vulnerable plaques. We here review current information on this topic.

METHODS

We systematically reviewed the literature for concepts derived from pathophysiologic, histopathologic, and clinical studies on imaging techniques attempting at identifying vulnerable carotid lesions.

RESULTS

Ultrasound, MRI, CT, and nuclear medicine-based techniques, alone or with multimodality approaches, all have a link to pathophysiology and describe different-potentially complementary-aspects of lesions prone to complications. There is also, however, a true paucity of head-to-head comparisons of such techniques for practical implementation of a thorough and cost-effective diagnostic strategy based on evaluation of outcomes. Especially in asymptomatic patients, major international societies leave wide margins of indecision in the advice to techniques guiding interventions to prevent atherothrombotic stroke.

CONCLUSIONS

To improve practical management of such patients-in addition to the patient's vulnerability for systemic reasons-a more precise identification of the vulnerable plaque is needed. A better definition of the diagnostic yield of each imaging approach in comparison with the others should be pursued for a cost-effective translation of the single techniques. Practical translation to guide future clinical practice should be based on improved knowledge of the specific pathophysiologic correlates and on a comparative modality approach, linked to subsequent stroke outcomes.

Reductions in perceived stress following Transcendental Meditation practice are associated with increased brain regional connectivity at rest

Transcendental Meditation (TM) is defined as a mental process of transcending using a silent mantra. Previous work showed that relatively brief period of TM practice leads to decreases in stress and anxiety. However, whether these changes are subserved by specific morpho-functional brain modifications (as observed in other meditation techniques) is still unclear. Using a longitudinal design, we combined psychometric questionnaires, structural and resting-state functional magnetic resonance imaging (RS-fMRI) to investigate the potential brain modifications underlying the psychological effects of TM. The final sample included 19 naïve subjects instructed to complete two daily 20-min TM sessions, and 15 volunteers in the control group. Both groups were evaluated at recruitment (T0) and after 3 months (T1). At T1, only meditators showed a decrease in perceived anxiety and stress (t₍₁₈₎ = 2.53, p = 0.02), which correlated negatively with T1-T0 changes in functional connectivity among posterior cingulate cortex (PCC), precuneus and left superior parietal lobule. Additionally, TM practice was associated with increased connectivity between PCC and right insula, likely reflecting changes in interoceptive awareness. No structural changes were observed in meditators or control subjects. These preliminary findings indicate that beneficial effects of TM may be mediated by functional brain changes that take place after a short practice period of 3 months.

Surgical margin follow-up after nephron-sparing surgery: the possible role of CEUS

PURPOSE

To evaluate the possible role of CEUS in the management of patients who underwent nephron-sparing surgery (NSS) and presented questionable findings on the surgical margins at the CECT follow-up exam.

METHODS

In our retro-prospective study, we included 952 patients with small renal masses (SRMs) treated with NSS between 2012 and 2015 and followed with CECT for at least 3 years at Careggi University Hospital. Twenty-two of them presented solid masses on the site of surgery with questionable enhancement at CECT and were further studied with CEUS. This examination was followed by a quantitative analysis of the enhancement pattern.

RESULTS

Out of the 22 masses, 18 were considered possible granulomas, presenting slow wash-in and low enhancement peaks compared to the surrounding parenchyma and persistent delayed wash-out at CEUS. Four lesions presented a suspicious malignant enhancement pattern, with rapid wash-in, high peak and rapid wash-out. In accordance with instructions from the urologist, the first group of 18 patients was strictly monitored, revealing that the mass dimensions and enhancement pattern were stable for at least 3 years of follow-up, while the other 4 patients underwent a second intervention and their masses were confirmed as tumor recurrence at the histopathological evaluation.

CONCLUSIONS

CEUS can play a key role in the surgical margin follow-up after NSS when a suspicious enhancing mass is detected by CECT, giving an accurate depiction of the enhancement pattern and thus helping the clinician in the management of the patient.

P2538Arterial stiffness and remodeling from large to small arteries in patients with spontaneous coronary artery dissection: evidence for a systemic subclinical involvement

Background and aim

Spontaneous coronary artery dissection (SCAD) is a major cause of acute coronary syndrome in women aged 50 years or less (22–43%). Its etiology is still unknown, though an association with systemic diseases such as fibromuscular dysplasia and collagenopathies has been found. This study is aimed at investigating the presence of subclinical structural and functional alterations in extracoronary districts in SCAD patients.

Methods

The design was a case-control study. Carotid, radial and digital arteries were scanned by standard or ultrahigh frequency ultrasound; clips were analyzed by automated image analysis software for diameter, intima-media thickness (IMT) and local distensibility. Applanation tonometry was used to obtain carotid-femoral pulse wave velocity, a measure of regional, aortic stiffness, and carotid pressure waveform.

Results

30 patients previously diagnosed with SCAD (27 women, age 51±10 years, 8 treated hypertensives, 4 smokers, mean BP 83±11mmHg, BMI 25±5kg/mq) and 30 controls, matched for age, sex and CV risk factors by propensity score, were enrolled. 18 SCAD patients underwent PTCA and 6 had a diagnosis of extracoronary fibromuscular dysplasia. In the left radial artery, wall thickness, cross-sectional area (2.96±1.07 vs 1.79±1.41mm2, p=0.008), and wall inhomogeneity were increased, especially in the outer layer, whereas diameter, wall/lumen ratio and distensibility were comparable to controls. In the left common carotid artery, an increased carotid stiffness was shown in SCAD (5.99±0.89 m/s vs 5.6±0.85, 0.03), while IMT tended to be increased bilaterally (0.63±0.12 vs 0.59±0.10mm, p=0.08). Aortic stiffness was similar in the two groups (7.0±1.9 vs 6.7±1.7m/s, p=0.60). Carotid (20.4±14.2 vs 11.9±15.0%, p=0.03), but not aortic augmentation index, was increased bilaterally.

Conclusions

SCAD patients showed a peculiar pattern of alterations in vascular remodeling and stiffness in extracoronary arterial segments such as the carotid and radial arteries, supporting the hypothesis that a systemic susceptibility is present even in the absence of systemic diseases.

P2836Role of pre-procedural CT-imaging on catheter ablation in patients with atrial fibrillation: procedural outcomes and radiological exposure

Introduction

Cardiac computerized tomography (CT) is commonly used to study left atrial (LA) and pulmonary veins (PVs) anatomy before atrial fibrillation (AF) ablation. However, it remains unclear whether pre-procedural imaging actually is associated with an improvement of efficiency, efficacy, and safety.

Purpose

Aim of the the study was to determine the impact of pre-procedural imaging using CT with 3-D reconstruction on procedural outcomes and radiological exposure in patients who undergo radiofrequency catheter ablation (RFA) to eliminate AF.

Methods

In this registry, 493 consecutive patients (age 62±8 years, 70% male) with paroxysmal (316) or persistent (177) AF who underwent RFA were included. A CT scan was obtained in 324 (66%) patients (CT Group) prior to RFA, while 169 (34%) didn't have any pre-procedural imaging (No-CT Group). Antral PVs isolation was performed in all patients along using an open-irrigation-tip catheter with a 3-D electroanatomical navigation system. Additional ablation applications were targeted if required. Procedural outcome, including radiological exposure, and clinical outcomes were compared among patients who underwent RFA with (CT-Group) and without (No CT-Group) pre-procedural imaging.

Results

Acute PV isolation was obtained in all patients. Additional ablation targets were targeted along the CTI (71/324 [22%] vs. 40/169 [24%], P=NS), the roof line (74/324 [23%] vs. 40/169 [24%], P=NS), the mitral isthmus (33/324 [10%] vs. 12/169 [7%], P=NS) and CFAEs (28/324 [8.6%] vs. 12/169 [7.1%], P=NS), without significant differences among groups. Complication rate were comparable between CT and No CT patients (4.3% vs 3%, P=0.7). In one Redo procedure of the No-CT Group, for the impossibility of identifying left PVs, a 3D LA fluoro-angiography was performed, which confirmed a left PVs occlusion. (Figure) No differences were observed about mean duration of the procedure (231±60 vs 233±58 min, P=0.7) and fluoroscopy time (13±10 vs 13±8 min, P=0.6) between groups. Cumulative radiation dose resulted significantly higher in the CT-Group (8.9±24 vs 4.8±15 mSV, P=0.02). Compared to paroxistical AF, persistent AF patients showed a comparable procedural-ED (6.6±26 vs 6±19, P=0.8) but with an higher CT-ED (1.7±2.9 vs 1.1±1.9, P=0.01).At 1 year, 227/324 (70%) and 119/169 (70%) of the patients who did and did not have pre-procedural imaging were free from AF (P = NS).

Figure 1

Conclusions

Pre-procedural CT does not improve safety and efficacy of AF ablation, increasing significantly the cumulative radiological exposure. Considering that patients candidate to AF ablation are often young, the cumulative radiation dose per life span and radiation dose reduction strategies should remain a matter of concern for doctors.

Acknowledgement/Funding

None

The efficacy of Ultra-High Frequency Ultrasonography in the diagnosis of intraoral lesions

OBJECTIVES

The aim of the present study was to evaluate the diagnostic efficacy of ultra-high frequency ultrasound (UHFUS) imaging of intraoral soft tissue lesions.

STUDY DESIGN

The study included 160 patients presenting with oral soft tissue lesions classified into 4 categories: autoimmune diseases, mucosal growths, potentially (pre)malignant lesions, and oral cancer. Each lesion was evaluated by means of intraoral UHFUS, through B-mode and C-mode acquisitions of the area of interest. The UHFUS findings were compared with the histopathologic findings.

RESULTS

All values for sensitivity, specificity, and negative predictive value exceeded 90%. Sensitivity was perfect (100%) for mucosal growths and oral cancer. Specificity was almost perfect for all 4 categories of lesions, ranging from 97% to 99%. Values for positive predictive value ranged from 83% to 99%.

CONCLUSIONS

UHFUS was beneficial in imaging the oral mucosa and the superficial aspects of the underlying soft tissue in detail because of the high spatial resolution of the technique. Consistent patterns were recognized for different categories of lesions. UHFUS holds the promise of being a valuable support to the clinician in terms of diagnosis, treatment, and follow-up of oral lesions.

Intraoral Ultra-High Frequency Ultrasound study of oral lichen planus: A pictorial review

BACKGROUND

Ultra-High Frequency Ultrasound (UHFUS) is a recently introduced diagnostic technique involving the use of higher frequencies compared to conventional ultrasound. Among the several fields of application, intraoral usage of UHFUS appears still limited. We report the intraoral evaluation of Oral Lichen Planus (OLP) by means of UHFUS and describe typical UHFUS aspect of different forms of presentation of OLP.

MATERIALS AND METHODS

Patients with clinical and histological diagnosis of OLP were enrolled in the study. OLP lesions were evaluated by means of intraoral UHFUS performed at 70 MHz, using B-mode and C-mode, in order to characterize the echostructure of each form of presentation.

RESULTS

Fifty patients in total were enrolled, and UHFUS features were described for different OLP forms. All the lesions showed a thick, hypoechoic superficial layer in the mucosal stratum, suggesting that such UHFUS alteration can be pathognomonic of OLP.

CONCLUSION

Ultra-High Frequency Ultrasound was able to differentiate superficial alterations of the oral mucosa, giving insight on possible applications of UHFUS in the study of OLP beyond clinical and histological investigations. Due to a limited study sample, we cannot draw firm conclusions. However, it is reasonable to think that UHFUS evaluation of OLP may provide useful information to the clinician.

Percutaneous Venous Angioplasty in Patients with Multiple Sclerosis and Chronic Cerebrospinal Venous Insufficiency: A Randomized Wait List Control Study

BACKGROUND

Venous percutaneous transluminal angioplasty (vPTA) in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency (CCSVI) have shown contradictory results. The aim of the study is to evaluate the efficacy of the procedure in a randomized wait list control study.

METHODS

66 adults with neurologist-confirmed diagnosis of MS and sonographic diagnosis of CCSVI were allocated into vPTA-yes group (n = 31) or vPTA-not group (n = 35, control group). vPTA was performed immediately 15 days after randomization in the PTA-yes group and 6 months later in the control group. Evoked potentials (EPs), clinical-functional measures (CFMs), and upper limb kinematic measures (ULKMs) were measured at baseline (T0) and six months after in both groups, just before the venous angioplasty in the vPTA-not group (T1).

RESULTS

Comparing the vPTA-yes and vPTA-not group, the CFM-derived composite functional outcome showed 11 (37%) versus 7 (20%) improved, 1 (3%) versus 3 (8%) stable, 0 versus 7 (20%) worsened, and 19 (61%) versus 18 (51%) mixed patients (χ² = 8.71, df = 3, P = 0.03). Unadjusted and adjusted (for baseline confounding variables) odds ratio at 95% confidence interval were, respectively, 1.93 (1.3-2.8), P value 0.0007, and 1.85 (1.2-1.7), P value 0.002. EP- and ULKM-derived composite functional outcome showed no significant difference between the two groups.

CONCLUSIONS

Venous angioplasty can positively impact a few CFMs especially for the quality of life but achieving disability improvement is unlikely.

Early Tumor Shrinkage and Depth of Response Evaluation in Metastatic Pancreatic Cancer Treated with First Line Chemotherapy: An Observational Retrospective Cohort Study

Early tumor shrinkage (ETS) and depth of response (DoR) predict favorable outcomes in metastatic colorectal cancer. We aim to evaluate their prognostic role in metastatic pancreatic cancer (PC) patients treated with first-line modified-FOLFIRINOX (FOLFOXIRI) or Gemcitabine + Nab-paclitaxel (GemNab). Hence, 138 patients were tested for ETS, defined as a ≥20% reduction in the sum of target lesions’ longest diameters (SLD) after 6–8 weeks from baseline, and DoR, i.e., the maximum percentage shrinkage in the SLD from baseline. Association of ETS and DoR with progression-free survival (PFS) and overall survival (OS) was assessed. ETS was reached in 49 patients (39.5% in the FOLFOXIRI, 29.8% in the GemNab group; p = 0.280). In the overall population, ETS was significantly associated with better PFS (8.0 vs. 4.8 months, p < 0.001) and OS (13.2 vs. 9.7 months, p = 0.001). Median DoR was −27.5% (−29.4% with FOLFOXIRI and −21.4% with GemNab, p = 0.016): DoR was significantly associated with better PFS (9.0 vs. 6.7 months, p < 0.001) and OS (14.3 vs. 11.1 months, p = 0.031). Multivariate analysis confirmed both ETS and DoR are independently associated with PFS and OS. In conclusion, our study added evidence on the role of ETS and DoR in the prediction of outcome of PC patients treated with first-line combination chemotherapy.

Radiologist-rheumatologist multidisciplinary approach in the management of axial spondyloarthritis: a Delphi consensus statement

OBJECTIVES

The aim of this study was to develop a Delphi consensus statement between rheumatologists and radiologists for the diagnosis and monitoring of axial spondyloarthritis (axial-SpA).

METHODS

Following an extensive literature search to identify unmet needs and potential goals for a multidisciplinary approach, a scientific board comprising 28 Italian hospital-based rheumatologists (n=19) and radiologists (n=9) identified 8 "starting points", resulting in the development of 23 consensus statements covering issues from current practice guidelines to specific MRI protocols for the assessment of axial-SpA. Each participant anonymously expressed a level of agreement for each statement using a 5-point Likert scale (1="strongly disagree"; 5="strongly agree") via an online Delphi method.Total cumulative agreement (TCA) was defined as the sum of the percentage of response to items 4 ("agree") and 5 ("absolutely agree"). Consensus was defined as ≥80% total cumulative agreement for each statement.

RESULTS

After the first round of voting (28 participants), positive consensus was reached for 28/31 (90.3%) statements. Statements without consensus (n=3) were discussed in a face-to-face plenary session prior to the second vote (28 participants). After the second round voting, positive consensus was attained for all 31 statements, with mean final TCA of 95.5% (range 82.1-100%).

CONCLUSIONS

This Delphi consensus statement provides an aid to rheumatologists and radiologists for the diagnosis and monitoring of axial-SpA.

Cone Beam CT study of a case of eosinophilic granuloma of the mandible in a young patient

Eosinophilic granuloma (EG) is a rare bony disease deriving from abnormal proliferation of histiocytes, and is the most common form of presentation of Langerhans cell histiocytosis. EG predominantly affects the axial skeleton. However, when localised in the head and neck district, mandibular lesions account for the majority of cases. Mandibular lesions can mimic other pathological conditions, making biopsy fundamental for differential diagnosis. Treatment depends on the severity of the disease, ranging from pharmacological treatment to surgical approach. However, EG is also reported to possibly undergo spontaneous resolution. In this case report, we describe a rare case of EG with particularly aggressive behaviour in a young patient. Initially, local pharmacological treatment with intralesional administration of corticosteroids lead to worsening of the symptoms, increase in lesion's dimensions, and disruption of the cortical bone. A more invasive therapeutic approach involving radical surgery was then performed, with consequent resolution of the disease.

Comparison between radioiodine therapy and single-session radiofrequency ablation of autonomously functioning thyroid nodules: A retrospective study

OBJECTIVE

To compare the efficacy of Radioiodine (RI) and Radiofrequency ablation (RFA) in the treatment of autonomously functioning thyroid nodules (AFTNs). End-points: nodule volume reduction (NVR) and thyroid function normalization.

DESIGN, PATIENTS AND MEASUREMENTS

Twenty-two patients (2:20 M:F; 51.9 ± 13.9 years) affected by 25 AFTNs, treated by RFA were retrospectively compared with 25 patients (8:17 M:F; 57.2 ± 12.8 years) affected by a single AFTN treated by RI. Both group showed analogous characteristics as to age, gender, toxic/pretoxic phase and pretreatment nodule volume (calculated by the ellipsoid formula). Thyroid hormone levels and autoimmune thyroid profile were assessed before treatment. A fixed RI activity of 555 MBq (15 mCi) was administered. RFA was performed with an 18G, single-tipped electrode, by the "modified moving shot technique." Thyroid hormones were assessed and the nodule post-treatment volume calculated 12 months after treatment.

RESULTS

No statistical difference was found between the post-treatment NVR by comparing RI and RFA (P = 0.69). The volume reduction rates were 68.4 ± 28.9% and 76.4 ± 16.9% after RI and RFA, respectively. As to the thyroid function, 5/25 patients developed clinical hypothyroidism after RI. After RFA, all the 22 patients silenced their AFTN and normalized the thyroid hormones. Subclinical hypothyroidism was recorded in two patients after both RI and RFA. Thus, the functional therapeutic success, defined as the restoration of euthyroidism, was achieved in 18/25 (72%) patients treated by RI and in 20/22 (90.9%) treated by RFA.

CONCLUSIONS

No statistical difference in NVR was found between RI and RFA. All patients responded to RI but 5/25 were "over-treated" developing hypothyroidism. RFA was effective in all patients with no case of post-treatment clinical hypothyroidism. No radiation exposure and lower risk of post-treatment hypothyroidism might make RFA the favourite option especially for young patients.

Diagnosis by consensus: A case study in the importance of interdisciplinary interpretation of mummified remains

OBJECTIVE

The goal of this study is to demonstrate the need for interdisciplinary consensus and inclusion of mummy radiology specialists in analyses of mummified remains.

MATERIALS

This study uses paleoimaging data for an ancient Egyptian mummy at the Museum of Human Anatomy "Filippo Civinini".

METHODS

This study demonstrates the benefit of evaluation of mummified remains in a multi-disciplinary interpretive team.

RESULTS

The authors propose a diagnosis of DISH, additional signs of undifferentiated spondyloarthropathy, and lumbarisation of S1.

CONCLUSIONS

The process of diagnosis by consensus is essential to the analysis of mummified remains, which are complexly altered through natural and anthropogenic processes in the millennia subsequent to the individual's death.

SIGNIFICANCE

Mummy paleoimaging and paleopathology lacks a unifying set of standards. We present an example of the value to be found in the multi-disciplinary diagnosis by consensus approach.

LIMITATIONS

We discuss numerous challenges to accurate and meaningful interpretation that radiography of mummified remains pose.

SUGGESTIONS FOR FURTHER RESEARCH

While the authors do not seek to impose any single set of standards, we do recommend a larger discussion on the topic of (culture-specific) standardisation in mummy paleoimaging and paleopathology. We further recommend the development of an international, multi-disciplinary panel of paleoimaging interpreters.

Effect of CT Localizer Radiographs on Radiation Dose Associated With Automatic Tube Current Modulation: A Multivendor Study

OBJECTIVES

To assess the influence of the CT localizer radiograph on the automatic tube current modulation system of 7 CT scanners produced by 4 different CT manufacturers.

METHODS

The influence of the localizer orientation, table height, tube current and tube potential values on the radiation dose of the related CT scan were evaluated. Images were acquired by using an anthropomorphic phantom positioned in the CT gantry isocenter as well as from -6 cm to +6 cm vertically to the isocenter.

RESULTS

Vertical movement of the CT table height affected the radiation dose in all scanners using anterior-posterior or a posterior-anterior localizer orientation albeit differently, depending on the manufacturer; only in 1/7 scanner no influence was observed. The latero-lateral localizer orientation proved to be more effective in limiting the influence of the vertical miscentering in all scanners. Changing localizer's tube voltage influenced the scan radiation dose in scanners produced by two manufacturers, while no significant effect was observed in scanners produced by the other two manufacturers. No significant dose variation was observed in 6/7 scanners when changing the localizer's tube current.

CONCLUSION

Localizer radiograph shows a significant influence on the radiation exposure but with different outcomes depending on the manufacturer of the CT scanner. Radiologists and radiographers should have a thorough understanding of these differences to assure patients the best examination in terms of radiation dose and image quality.

A propensity score-matched analysis of robotic versus open pancreatoduodenectomy for pancreatic cancer based on margin status

BACKGROUND

No study has shown the oncologic non-inferiority of robotic pancreatoduodenectomy (RPD) versus open pancreatoduodenectomy (OPD) for pancreatic cancer (PC).

METHODS

This is a single institution propensity score matched study comparing RPD and ODP for resectable PC, based on factors predictive of R1 resection (≤ 1 mm). Only patients operated on after completion of the learning curve in both procedures and for whom circumferential margins were assessed according to the Leeds pathology protocol were included. The primary study endpoint was the rate of R1 resection. Secondary study endpoints were as follows: number of examined lymph nodes (N), rate of perioperative transfusions, percentage of patients receiving adjuvant therapies, occurrence of local recurrence, overall survival, disease-free survival, and sample size calculation for randomized controlled trials (RCT).

RESULTS

Factors associated with R1 resection were tumor diameter, number of positive N, N ratio, logarithm odds of positive N, and duodenal infiltration. The matching process identified 20 RPDs and 24 OPDs. All RPDs were completed robotically. R1 resection was identified in 11 RPDs (55.0%) and in 10 OPDs (41.7%) (p = 0.38). There was no difference in the rate of R1 at each margin as well as in the proportion of patients with multiple R1 margins. RPD and OPD were also equivalent with respect to all secondary study endpoints, with a trend towards lower rate of blood transfusions in RPD. Based on the figures presented herein, a non-inferiority RCT comparing RPD and OPD having the rate of R1 resection as the primary study endpoint requires 3355 pairs.

CONCLUSIONS

RPD and OPD achieved the same rate of R1 resections in resectable PC. RPD was also non-inferior to OPD with respect to all secondary study endpoints. Because of the high number of patients required to run a RCT, further assessment of RPD for PC would require the implementation of an international registry.

mRECIST criteria to assess recurrent thyroid carcinoma treatment response after radiofrequency ablation: a prospective study

PURPOSE

Surgical removal is recommended for recurrent thyroid carcinomas (RTCs) unable to uptake radioiodine and/or not responsive to chemotherapy. However, repeated neck dissection is difficult for surgeons. Thus, radiofrequency ablation (RFA) was proposed for RTCs. The aim of this prospective study is to assess RTC treatment response after RFA, according to well-established criteria.

METHODS

Sixteen lesions in 13 patients were treated by RFA. All patients refused/were excluded from repeated surgery or other conventional therapy. CT and US examinations were performed before RFA to evaluate lesion volume and vascularization. All RFA procedures were performed under US-guidance by an 18-gauge, electrode. Treatment response was evaluated by CT, according to RECIST 1.1 and to mRECIST guidelines; CT examinations were performed during follow-up (6-18 months); the volume of residual vital tumour tissue and the percentage of necrotic tissue were estimated by contrast enhanced CT.

RESULTS

RFA was well tolerated by all patients; in two cases laryngeal nerve paralysis was observed. Mean pre-treatment volume was 4.18 ± 3.53 ml. Vital tumour tissue and percentage of necrosis at 6, 12 and 18 months were 0.18 ± 0.25, 0.11 ± 0.13, 0.29 ± 0.40 ml and 91.9 ± 11.1, 90.4 ± 13.3, 80.8 ± 23.1%. According to RECIST 1.1, target lesion response was classified as complete response (CR) in one case, partial response (PR) in 11/16, stable disease in 4/16 cases. According to mRECIST, 11/16 cases were classified as CR and the remaining 5 as PR.

CONCLUSION

RFA is a safe procedure to treat the viable tumour tissue and to reduce the RTC volume; as to the criteria to assess treatment response, mRECIST appears to be more accurate.

Management of pregnancy-associated pancreatic cystic tumors: Review of the literature and results of a Pancreas Club Inc. Survey

BACKGROUND/OBJECTIVES

Management of patients with pregnancy-associated cyst pancreatic cystic tumors (PA-PCT) is complicated by lack of large series.

METHODS

A systematic literature review was conducted to extrapolate data on management of PA-PCT, and make a questionnaire on pending issues to be administered to the members of the Pancreas Club Inc.

RESULTS

The literature review demonstrated a total of 35 PA-PCT in 34 women, described exclusively in the form of case reports, and permitted the identification of eleven key questions to be addressed in the survey. The combined analysis of literature review and survery responses provided several information. First, PA-PCT are predominantly located in the body-tail of the pancreas, cause non-specific symptoms, are of large size (mean size: 11.2 ± 4.5 cm), and are nearly always malignant or premalignant, making timing of surgery, and not indication for surgery, the main issue in the management of these tumors. Second, there is a risk of PA-PCT rupture during pregnancy. Ruptured PA-PCT had a mean size 13.5 ± 4.9 cm, but no prognostic factor could be identified. Survey opinions suggested that this occurrence is quite rare, even for large tumors. Third, most pregnancies were conducted to term (mean gestational age: 40.5 ± 0.7 weeks), with a vaginal delivery. Fourth, all procedures were carried out through an open approach and the spleen was rarely preserved. Survey indicated instead that laparoscopy could play a role, and that the spleen should be preserved when feasible.

CONCLUSIONS

PA-PCT require individualized treatment. The definition of a management algorithm requires the implementation of an International Registry.

Severe atherosclerosis in the natural mummy of Girolamo Macchi (1648-1734), "major writer" of Santa Maria della Scala Hospital in Siena (Italy)

BACKGROUND AND AIMS

A small crypt in the Santissima Annunziata Church of Santa Maria della Scala Hospital in Siena (Italy) contained three well-preserved mummies, two of which, dated back to the 15th-16th century, were identified as Salimbene Capacci (1433-1497), Rector of the Hospital, and his wife, Margherita Sozzini (?-1511). The third mummy, dressed in clothes of the 17th century, was not initially identified.

METHODS

Accurate bibliographical, taphonomic and anthropological studies allowed the identification of the mummy of Girolamo Macchi, who lived between 1648 and 1734 and worked as "major writer", an accountant, for the Hospital. He was present when the corpses of the Rector and his wife were discovered in 1678 and, impressed by this finding, wanted to be buried in the same chapel after his death, which occurred at the age of 86. A complete study, including macroscopic, radiological, isotopic and histological analyses, was performed on the natural mummy of Girolamo.

RESULTS

Macroscopic investigation showed a large inguinoscrotal hernia and a good preservation of the internal organs. The circulatory system revealed severe atherosclerosis, with multiple calcifications stenosing the lumen of the vessels, in particular of the lumbar aorta and the iliac arteries. The diagnosis was confirmed by imaging techniques (3D Cone Beam Scan) and by histology.

CONCLUSIONS

This case confirms that atherosclerosis is also a disease of ancient times. The presence of atherosclerosis in pre-contemporary individuals could suggest that the disease may not only be uniquely characteristic of a specific diet or lifestyle, but it could be also an inherent component of human ageing.