Diagnostic Performance of Dual-Energy CT for Detecting Painful Hip Prosthesis Loosening

Background Revisions of hip prostheses are increasing, and conventional radiography (CR) is a primary tool for managing -complications. However, dual-energy CT (DECT) with virtual monoenergetic imaging is capable of reducing periprosthetic metal artifacts compared with standard CT. Purpose To compare the diagnostic performance of DECT and CR in detecting hip prosthesis loosening, using surgery as a reference for diagnosis. Materials and Methods This retrospective single-center study conducted between January 2018 and October 2020 included -consecutive patients with unilateral painful hip prostheses. Two independent readers (with 15 years and 4 years of experience) who were blinded to clinical findings evaluated CR and DECT images. At imaging, diagnosis of loosening prosthesis was made for -periprosthetic radiolucency greater than or equal to 2 mm wide or the presence of two or more secondary findings, including -periprosthetic osteolysis, angulation of the implant, fracture, or abnormal periosteal reaction. For each reader and for each imaging parameter, -sensitivity and specificity were calculated. The diagnostic performance of each imaging tool was compared by using the McNemar test. Interobserver agreements were calculated with Cohen κ statistics. Statistical software was used. Results Overall, 178 patients (mean age ± standard deviation, 74 years ± 20; 96 men) were included (121 undergoing surgery, 57 follow-up). Overall, 87 of 178 patients (49%) were diagnosed with a loosened prosthesis. DECT had higher sensitivity and specificity than CR for both reader 1 (94% [82 of 87 examinations; 95% CI: 87, 98] and 93% [85 of 91 examinations; 95% CI: 86, 97] vs 84% [73 of 87 examinations; 95% CI: 74, 91] and 91% [83 of 91 examinations; 95% CI: 83, 96], respectively; P < .001) and reader 2 (92% [80 of 87 examinations; 95% CI: 84, 97] and 95% [86 of 91 examinations; 95% CI: 88, 98] vs 80% [70 of 87 -examinations; 95% CI: 71, 88] and 91% [83 of 91 examinations; 95% CI: 83, 96], respectively; P = .001), with better interobserver agreement (κ, 0.88 [95% CI: 0.81, 0.95] vs 0.78 [95% CI: 0.69, 0.88]). Conclusion Dual-energy CT showed better diagnostic performance than conventional radiography in diagnosing hip prosthesis loosening. See also the editorial by Lutz in this issue. © RSNA, 2021.

Anosognosia for theory of mind deficits: A single case study and a review of the literature

Being aware of one's own ability to interact socially is crucial to everyday life. After a brain injury, patients may lose their capacity to understand others' intentions and beliefs, that is, the Theory of Mind (ToM). To date, the debate on the association between ToM and other cognitive deficits (in particular executive functions and behavioural disorders) remains open and data regarding awareness of ToM deficits are meagre. By means of an ad-hoc neuropsychological battery of tests, we report on a patient who suffers from ToM deficits and is not aware of these disorders, although aware of his other symptoms. The study is accompanied by a review of the literature (PRISMA guidelines) demonstrating that ToM deficits are independent of executive functions. Furthermore, an advanced lesion analysis including tractography was executed. The results indicate that: i) ToM deficits can be specific and independent of other cognitive symptoms; ii) unawareness may be specific for ToM impairment and not involve other disorders and iii) the medial structures of the limbic, monitoring and attentional systems may be involved in anosognosia for ToM impairment.

Identification of bone marrow edema around the ankle joint in non-traumatic patients: Diagnostic accuracy of dual-energy computed tomography

OBJECTIVES

To evaluate the diagnostic accuracy of DECT in the identification of BME of the ankle in non-traumatic patients.

METHODS

This prospective institutional review board approved study included 40 consecutive patients (21 males and 19 females, mean age 56.8 years, SD = 11.37) that were examined using DECT and MRI in the period between April 2019 and January 2020. Two radiologists (7 and 16 years of experience) evaluated the presence of BME on DECT mages. Diagnostic accuracy values for diagnosing BME on a per-patient and on a per-partition basis analysis were calculated for DECT images by two readers (R1 and R2, with 16 and 7 years of experience, respectively), using MRI as a gold-standard for diagnosis. Inter-observer agreements were calculated with k-statistics. A p-value of <0.05 was considered as statistically significant.

RESULTS

MRI depicted BME in 29/40 patients (72.50%) and in 43/240 partitions (17.91%). The consensus reading by R1 and R2 of DECT images allowed us to achieve 89.7% sensitivity (26/29 patients) and 81.8% specificity (9/11 patients). Regarding the partitions-basis analysis, BME was depicted by DECT in 39/43 partitions (90.69% sensitivity), and ruled out in 189/197 partitions (95.93% specificity). Sensitivity and specificity for the most involved partitions (talar dome) were both 95%. The inter-observer agreement for patients' analysis was substantial (k = 0.697), whereas for the partitions' analysis, it ranged from substantial (k = 0.724) to near perfect (k = 0.950).

CONCLUSIONS

DECT can accurately diagnose BME of the ankle in a cohort of non-traumatic patients.

Identification of pulmonary embolism: diagnostic accuracy of venous-phase dual-energy CT in comparison to pulmonary arteries CT angiography

OBJECTIVES

To evaluate the diagnostic accuracy of venous-phase dual-energy computed tomography (VP-DECT) in the identification of PE compared with standard CT pulmonary angiography (CTPA).

METHODS

This prospective IRB-approved study included 61 consecutive oncology patients (35 females, 26 males, mean age 66.91 years) examined by CTPA and VP-DECT. DECT data were post-processed on a SyngoVia workstation to obtain monoenergetic images (MEI+). The diagnosis of PE was based on the presence of any vascular perfusion defects. DECT images were evaluated independently by two radiologists (8 and 16 years of experience). A consensus reading of CTPA images (two senior radiologists, 18 and 24 years of experience) represented the reference for diagnosis. The diagnostic accuracy values of VP-DECT on a per-patient and per-lobe basis were assessed. Interobserver agreement was calculated using k-statistics. A value of p < 0.05 was considered statistically significant.

RESULTS

Thirty of 61 patients (49.18%) were diagnosed with PE by CTPA, with 57/366 lobes being involved (15.57%). The sensitivity and specificity of the per-patient analysis of VP-DECT images were 90.0% (27/30) and 100% (31/31) respectively, for both readers. As concerns the per-lobe analysis, the sensitivity ranged from 100% for the right lower lobe to 50% for the left upper lobe for reader 1, and from 100% for the left upper lobe to 69.23% for the lingula for reader 2. The interobserver agreement ranged from 0.8671 (patients' analysis) to 0.6419 (lobes' analysis).

CONCLUSION

VP-DECT could be considered an accurate imaging tool for diagnosing PE in a selected, high-prevalence population, compared with CTPA.

KEY POINTS

• With regard to the patients' analysis, venous-phase DECT sensitivity and specificity in diagnosing pulmonary embolism were 90% and 100%, respectively, for both readers. • With regard to the lobes' analysis, the sensitivity ranged from 100 to 50%, for reader 1, and from 100 to 69.23%, for reader 2, respectively. • The sensitivity and specificity of lung perfusion maps obtained from venous DECT were 73.33% and 67.74% as concerns the patients' analysis and 71.92% and 75.72% as regards the lobes' analysis, respectively.

Radiographic and HRCT imaging findings of chronic pulmonary schistosomiasis: review of 10 consecutive cases

Objective:

To describe the chest radiography (CR) and the high resolution CT (HRCT) imaging findings of chronic pulmonary schistosomiasis (CPS)

Methods and materials:

This retrospective study included 10 patients suffering from CPS, studied between September 2013 and October 2016 by using CR and HRCT. Images were reviewed by two experienced radiologists in consensus, blinded to clinical data. A p value < 0.05 was considered significant

Results:

All the patients enrolled showed some abnormalities at HRCT, including lung consolidations, solid nodules, nodules with peri-nodular halo, ground-glass opacities, enlarged hilar lymph-nodes. Only seven patients showed findings at CR ( p = 0.001). At CT, none of the patients had significant pleural, vascular (pulmonary arteries) or cardiac findings. Post-therapy studies (mean interval 35 days) demonstrated the absence of residual disease in all patients.

Conclusion:

The imaging findings of CPS varied widely in our study population. HRCT may show signs which are occult on plain radiograph. All lesions disappeared after appropriate therapy at imaging follow-up studie.

Evaluation of glenoid labral tears: comparison between dual-energy CT arthrography and MR arthrography of the shoulder

OBJECTIVE

To compare the diagnostic accuracy of dual-energy computed tomography arthrography (DE-CTA) and magnetic resonance arthrography (MRA) of the shoulder in depicting glenoid labral tears.

METHODS

This prospective institutional review board-approved study included 47 consecutive patients (28 males, 19 females; mean age of 34.2 years) studied between January 2017 and October 2018. All patients underwent DE-CTA and MRA the same day. Two radiologists (25 and 11 years of experience, respectively), blinded to clinical data, evaluated the presence labral tears on virtual-blended 120 kV standard CTA and on DE-CTA images. A third radiologist (18 years of experience) evaluated the MRA images. Diagnostic accuracy values were calculated by using surgery as standard of reference. Inter-observer and intra-observer agreements were calculated with k statistics. A value of p < 0.05 was considered statistically significant.

RESULTS

Surgery revealed the presence of labral tears in 38/47 patients (80.9%). Sensitivity and specificity values in diagnosing labral tears were 84.2% and 77.8% for MRA (Reader 3), 84.2% and 77.8% for CTA (Reader 1), 84.2% and 88.9% for CTA (Reader 2), 89.5% and 88.9% for DE-CTA (Reader 1), and 92.1% and 88.9% for DE-CTA (Reader 2). A nonsignificant increase in AUC values with respect to MRA was obtained by reading the CTA (p = 0.470) and DE-CTA dataset (p = 0.217), respectively. Inter-observer agreements were near perfect for CTA (k = 0.84) and substantial for DE-CTA reading (k = 0.76). Intra-observer agreements were near perfect both for CTA (k = 0.88) and for DE-CTA reading (k = 0.82).

CONCLUSION

DE-CTA and MRA were not different in terms of diagnostic performance.

Identification of bone marrow edema of the ankle: diagnostic accuracy of dual-energy CT in comparison with MRI

OBJECTIVE

To evaluate the diagnostic accuracy of dual-energy computed tomography (DECT) to identify bone marrow edema (BME) of the ankle.

METHODS

This prospective institutional review board approved study included 40 consecutive patients (29 males and 11 females; mean age of 32.3 years) studied with DECT (80 kV and tin filter 150 kV) and MRI within 10 days. DECT data were post-processed for generating non-calcium images of the ankle. Two radiologists evaluated the presence of BME on color-coded maps. Diagnostic accuracy values for diagnosing BME were calculated for DECT maps (qualitative assessment) and for CT numbers (quantitative assessment) by using receiver operator curves and area under the curve (AUC), using MRI as the gold standard. Interobserver and intraobserver agreements were calculated with k-statistics. A p < 0.05 was considered statistically significant.

RESULTS

DECT depicted BME in 23/25 patients (92.0%). The sensitivity, specificity, PPV and NPV, and accuracy achieved by evaluating the DECT images were 92.0, 86.6, 92.0, 84.6, and 90.0%, for reader 1 and 88.0, 86.6, 91.6, 78.6, and 87.5, for reader 2, respectively. The interobserver and intraobsever agreements were near perfect (k = 0.87 and k = 0.83, respectively). DECT numbers were significantly different between positive (mean - 12.6 ± 29.6 HU) and negative cases (mean - 64.2 ± 34.5 HU) with a p value < 0.001. By using - 20HU cutoff to identify BME (AUC of 0.896.), the sensitivity, specificity, PPV and NPV, and accuracy of the quantitative analysis were 88.0, 92.6, 95.7, 92.6, and 87.5%, respectively.

CONCLUSION

DECT represents an accurate imaging tool for demonstration of BME of the ankle when compared to MRI.

La mielopatia in corso di artrite reumatoide a localizzazione cervicale

In corso di artrite reumatoide l'interessamento del rachide cervicale riguarda circa il 60–70% dei pazienti affetti dalla patologia. Le strutture colpite dalla flogosi reumatoide sono le articolazioni cartilaginee e sinoviali, le cosiddette articolazioni di Luschka, l'inserzione di tendini e legamenti e i tessuti molli della regione cervicale. Il coinvolgimento del tratto cervicale può essere asintomatico o rendersi responsabile di importante dolore, limitazione funzionale e di varie manifestazioni neurologiche, quali parestesie, paresi, ipotrofia muscolare, fino alla quadriplegia e morte, soprattutto in caso di malattia particolarmente aggressiva e perdurante da molto tempo.

In questo lavoro si è cercato di individuare i caratteri clinico-radiologici più significativamente associati a sintomatologia neurologica in corso di artrite reumatoide. Particolare attenzione è stata prestata per definire i caratteri morfologici ed il valore degli indici lineari indicatori di compressione midollare per lussazione atlo-assiale.

Dei 27 pazienti (24 donne e 3 uomini, età media di 61 anni) appartenenti alla casistica in esame, solo 3 (11,1%) presentavano esclusivo interessamento del tratto sub-assiale; 19 (70,3%) presentavano esclusivo interessamento radiologico della cerniera atlo-assiale, mentre in 5 (18,6%) era rilevabile coinvolgimento radiologico sia del tratto sub-assiale che della cerniera.

In base alla nostra esperienza, più della metà di questi pazienti sviluppa lussazione atlo-assiale; di questi, a loro volta, circa la metà presenta interessamento neurologico: è a questo gruppo, in cui più frequentemente ricorre la lussazione anteriore pura (nel 57% dei casi, contro il 37,5% di quelli privi di interessamento neurologico), cui deve essere prestata particolare attenzione in quanto suscettibile di trattamento chirurgico decompressivo (odontoidectomia) che può eliminare la causa di compressione midollare altrimenti destinata a «fissarsi» in maniera irreversibile con conseguenti gravissimi disturbi neurologici.

Questo gruppo di pazienti, in base alla nostra casistica, comprende una relativa maggior rappresentazione del sesso maschile, ed una durata media di malattia significativamente inferiore, con conseguente più breve periodo di accertata positività al FR; anche l'età media è significativamente inferiore, situandosi attorno ai 58 anni contro i 64,9 dei pazienti senza interessamento neurologico.

In questi pazienti il valore critico di 9 mm di distanza atlo-dentale è stato raggiunto e superato in più della metà dei casi, contro solo il 12,5% dei pazienti senza interessamento neurologico. Parimenti, più frequente è risultata la presenza di cospicuo panno infiammatorio; l'iper-intensità midollare, spia di mielopatia, è stata osservata solo in questi pazienti, nell'86% dei quali l'angolo bulbo-midollare era ristretto per impronta compressiva esercitata dal dente dell'epistrofeo.

La RM si è dimostrata eccellente strumento diagnostico per la valutazione del coinvolgimento del rachide cervicale in corso di artrite reumatoide: è l'unica indagine, infatti, che consente contemporaneamente la visualizzazione diretta del panno infiammatorio, del coinvolgimento del legamento trasverso e dei segni della mielopatia da compressione midollare.

Neuroendocrine Carcinoma of the Breast: Current Evidence and Future Perspectives

: Neuroendocrine carcinoma of the breast is considered a rare entity, and for this reason there are no data from prospective clinical trials on its optimal management. Early stage tumors are usually treated with the same strategy used for the other types of invasive breast cancer. Anthracycline- and taxane-based regimens represent the most frequently administered chemotherapy in neoadjuvant and adjuvant setting, as well as for metastatic disease, although combinations of platinum compounds and etoposide have been widely used, in particular for small-cell histology and tumors with a high proliferation index. For metastatic disease, a multimodality therapeutic strategy can be considered on an individual basis, with chemotherapy, endocrine therapy, peptide receptor radionuclide therapy, radiation therapy, surgery, or a combination of the above. In the near future, a better knowledge of the biology of these tumors will hopefully provide new therapeutic targets for personalized treatment. In this review, we discuss the current evidence and the future perspectives on diagnosis and treatment of neuroendocrine carcinoma of the breast.

IMPLICATIONS FOR PRACTICE

Neuroendocrine carcinoma of the breast (NECB) is a distinct entity of breast cancer. Clinical features and morphology are not helpful to distinguish NECB from other subtypes of breast cancer; therefore, immunohistochemistry markers for neuroendocrine differentiation, mainly chromogranin and synaptophysin, should be routinely used to confirm the diagnosis, especially in cases of mucinous or solid papillary carcinoma in which the suspicion of NECB may be relevant. Adjuvant treatment should be offered according to the same recommendations given for the other types of invasive breast cancer. An accurate diagnosis of NECB is also important in the metastatic setting, in which a multimodality approach including specific therapies such as peptide receptor radionuclide therapy can be considered.

Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer

PURPOSE

This study was done to verify the usefulness of preoperative breast magnetic resonance (MR) imaging in patients with newly diagnosed breast cancer.

MATERIALS AND METHODS

A retrospective analysis of 291 patients with invasive breast cancer newly diagnosed with conventional breast imaging (mammography and ultrasound) was performed. All patients underwent MR imaging prior to surgery. The MR imaging detection rate of additional malignant cancers occult to mammography and ultrasound was calculated. Data were analysed with Fisher's exact test (p<0.05) according to the following parameters: histopathological features of the index tumour (histological type and size) and mammographic density [according to the Breast Imaging Reporting and Data System (BI-RADS) classification from 1 fatty to 4 dense). The gold standard was the histological examination on the surgical specimen.

RESULTS

MR imaging identified 40 mammographically and sonographically occult malignant lesions other than the index cancer in 27/291 patients (9%). These additional cancers were located in the same quadrant as the index cancer in 13 women (4%), in a different quadrant in 12 (4%) and in the contralateral breast in the remaining two (1%). The cancer detection rate in the subgroup of index cancers with lobular histological type was 25%, significantly higher (p=0.03) than the detection rate of 11% recorded in the subgroup of ductal cancers. The cancer detection rate in the subgroup of index cancers >2 cm was 27%, significantly higher (p=0.001) than the rate of 8% found in the subgroup of index cancers <2 cm. Mammographic density was not correlated (p=0.48) with MR detection of additional cancer, with 14% of additional malignancies being detected in both dense and fatty breasts.

CONCLUSIONS

In patients with newly diagnosed invasive breast cancer, preoperative MR imaging is useful for detecting additional synchronous malignancies that are not detected on conventional breast imaging. The cancer detection rate is 9%. The use of preoperative MR imaging as an adjunct to conventional breast imaging in women with an infiltrating lobular index cancer and an index cancer >2 cm is especially beneficial.

Autoimmune pancreatitis: imaging findings on contrast-enhanced MR, MRCP and dynamic secretin-enhanced MRCP

PURPOSE

This study retrospectively determined magnetic resonance (MR), MR cholangiopancreatography (MRCP) and secretin-MRCP findings in patients with autoimmune pancreatitis (AIP).

MATERIALS AND METHODS

The MR examinations of 28 patients with histopathologically proven AIP were reviewed. In 14 cases, secretin-enhanced MRCP was performed. The observers evaluated pancreatic parenchymal enlargement, signal intensity abnormalities, enhancement, vascular involvement, bile-duct diameter and main pancreatic duct (MPD) narrowing (diffuse/focal/segmental). After secretin administration, the presence of the "duct-penetrating" sign was evaluated.

RESULTS

MR imaging showed diffuse pancreatic enlargement in 8/28(29%) cases, focal pancreatic enlargement in 16/28 (57%) cases and no enlargement in 4/28 (14%) cases. The alteration of pancreatic signal intensity was diffuse in 8/28 (29%) cases (eight diffuse AIP) and focal in 20/28 (71%) cases (20 focal AIP). Delayed pancreatic enhancement was present in all AIP, with peripheral rim of enhancement in 8/28 (29%) AIP (1/8 diffuse, 7/20 focal); vascular encasement was present in 7/28 (25%) AIP (1/8 diffuse, 6/20 focal); distal common bile duct narrowing was present in 12/28(43%) AIP (5/8 diffuse, 7/20 focal). MRCP showed MPD narrowing in 17/28 (61%) AIP (4/8 diffuse, 15/20 focal), MPD dilation in 8/28(29%) AIP (3/8 diffuse, 5/20 focal) and normal MPD in 1/8 diffuse AIP. Secretin-MRCP showed the duct-penetrating sign in 6/14(43%) AIP (one diffuse AIP with MPD segmental narrowing, five focal AIP with MPD focal narrowing), demonstrating integrity of the MPD.

CONCLUSIONS

Delayed enhancement and MPD stenosis are suggestive for AIP on MR and MRCP imaging. Secretin-enhanced MRCP is a problem-solving tool in the differential diagnosis between focal AIP and ductal adenocarcinoma.

Combined radiofrequency and kyphoplasty in painful osteolytic metastases to vertebral bodies

PURPOSE

The aim of this study was to assess retrospectively the safety and efficacy of combined radiofrequency (RF) and kyphoplasty (KP) in managing painful osteolytic metastases to vertebral bodies resistant to conservative treatments.

MATERIALS AND METHODS

Eleven patients (9 women and 2 men; mean age 68 years; age range 58-82) with painful osteolytic vertebral body metastases unresponsive to conservative treatments underwent RF combined with KP under general anaesthesia. Primary neoplasms were kidney carcinoma (n=1), breast carcinoma (n=1), thyroid carcinoma (n=2) and multiple myeloma (n=7). Lesion levels were cervical (n=1), thoracic (n=9) and lumbar (n=1). Combined RF and KP was well-tolerated by all patients. The procedures were performed using fluoroscopic guidance and intraoperative neurophysiology monitoring. Pain relief with the visual analogue scale (VAS) pain score and analgesic consumption were evaluated before and after treatment.

RESULTS

No complication occurred. In one case, we observed an asymptomatic cement leakage. Pain significantly decreased after treatment: the mean VAS pain score before treatment was 8 (range 7-10) vs. 1.8 (range 0-3) and 1.9 (range 1-3), respectively, 72 h and 6 weeks after the treatment. Analgesic reduction was achieved in all patients.

CONCLUSIONS

RF combined with KP represents a potential alternative method for palliation of painful spinal osteolytic metastases in selected patients. The procedures are safe and provide pain relief with bone augmentation and improvement in quality of life.

Autoimmune pancreatitis: CT patterns and their changes after steroid treatment

PURPOSE

To retrospectively evaluate the computed tomographic (CT) patterns of autoimmune pancreatitis (AIP) and their changes after steroid therapy.

MATERIALS AND METHODS

Investigational review board approval was obtained, and the informed consent requirement was waived. The medical and imaging data of 21 patients (13 men, eight women; mean age, 47.5 years; age range, 25-79 years) with histopathologically proved AIP who underwent contrast material-enhanced CT at diagnosis and after steroid treatment were included in this study. Image analysis included assessment of the (a) presence or absence and type (focal or diffuse) of pancreatic parenchyma enlargement, (b) contrast enhancement of pancreatic parenchyma, (c) size of the main pancreatic duct (MPD) within the lesion and upstream, and (d) pancreatic parenchyma thickness in the head, body, and tail of the pancreas. The same criteria were applied to follow-up CT examinations, the follow-up data were compared with pretreatment data, and a paired sample t test was applied.

RESULTS

Pancreatic parenchyma showed focal enlargement in 14 (67%) patients and diffuse enlargement in seven (33%). Pancreatic parenchyma affected by AIP appeared hypoattenuating in 19 (90%) patients and isoattenuating in two (10%). During the portal venous phase, pancreatic parenchyma showed contrast material retention in 18 (86%) patients and contrast material washout in three (14%). The MPD was never visible within the lesion. After treatment, there was a reduction in the size of pancreatic parenchyma segments affected by AIP (P < .05). Fifteen (71%) of the 21 patients had a normal enhancement pattern in the pancreatic parenchyma, whereas the enhancement pattern remained hypovascular in six (29%). The MPD returned to its normal size within the lesion in all patients at follow-up CT. In one of the eight patients with focal forms of AIP, the upstream MPD remained dilated.

CONCLUSION

AIP appeared as pancreatic parenchyma enlargement, with MPD stenosis within the lesion and upstream dilatation in focal forms of AIP. After steroid treatment, there was normalization of these findings.

Collateral branches IPMTs: secretin-enhanced MRCP

Recently, the fantastic evolution of imaging modalities (especially MR, MDCT, EUS) has raised many issues regarding the correct classification of smaller and smaller lesions, their preoperative evaluations, and indications of most appropriate treatment. However, it is still debated which technique should be employed for the diagnosis and the follow-up of intraductal papillary mucinous tumours (IPMTs). Despite the superb spatial resolution of MDCT, nowadays most of the authors agree on considering MR with magnetic resonance cholangiopancreatography (MRCP) the imaging modality of choice in studying IPMTs. In particular, MRCP is rapid, non-invasive, and accurate in detecting, localizing, and correctly classifying IPMT. The diagnostic performance of MRCP is even improved after the introduction of secretin stimulation. In fact, dynamic MRCP studies after secretin administration, besides facilitating the depiction of the structural characteristics of the lesions, make easier the detection of the communicating duct of branch duct IPMTs with the main pancreatic duct, especially if the newest high resolution 3D heavily T2-weighted sequences are utilized. Secretin stimulation is also useful in the demonstration of early changes of associated chronic pancreatitis. Consequently, we believe that secretin-enhanced MRCP is the most suitable imaging modality in the diagnosis and follow-up of IPMTs of the collateral branches.

Assessment of pelvic endometriosis: correlation of US and MRI with laparoscopic findings

PURPOSE

The purpose of this study was to evaluate the contribution of ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis and local staging of endometriosis by comparing results with laparoscopic findings.

MATERIALS AND METHODS

We evaluated 36 consecutive women with suspected or clinically diagnosed endometriosis. Thirty-two out of 36 patients met the following inclusion criteria: transabdominal and endocavitary (US) examination and MR imaging, followed by laparoscopy performed within 2 weeks. US and MR findings were classified based on location, number and morphology (small nodules, large nodules, laminar lesions, cystic lesions, complex lesions, adhesions, cul-de-sac obliteration).

RESULTS

Laparoscopy, considered the gold standard, identified 143 lesions in 32 patients. US detected 101 lesions, and MR detected 92 lesions, which were subsequently divided by morphologic appearance. Sensitivity and specificity of the two imaging techniques in the recognition of the different locations were 58% and 25%, respectively, for US and 56% and 50%, respectively, for MR imaging. Results of the two techniques in the different locations examined were similar, with the exception of lesions in the rectovaginal septum, which were better detected by US, and for adhesions and cul-de-sac obliteration, which were more easily detected by MR.

CONCLUSIONS

Both US and MR are accurate in the diagnosis of endometriosis. There are no significant differences in staging of pelvic endometriosis between US and MR. US examination is the primary evaluation in cases of suspected disease and for the rectovaginal septum. MR examination is recommended for correct classification in doubtful cases and in cases of suspected extrapelvic lesions and adhesions.

Angiosonography in suspicious breast lesions with non-diagnostic FNAC: comparison with power Doppler US

PURPOSE

The purpose of this study was to evaluate the accuracy of angiosonography in comparison with colour Doppler ultrasound (US) in the discrimination of suspicious breast lesions with nondiagnostic fine-needle aspiration cytology (FNAC).

MATERIALS AND METHODS

Pre-operative Power Doppler US and angiosonography were prospectively performed in 20 suspicious breast lesions with non-diagnostic FNAC. A second-generation US contrast agent was utilised with a high-frequency transducer and a contrast-specific algorithm (low acoustic pressure CnTI). The enhancement characteristics of all lesions were analysed using qualitative and quantitative parameters obtained from time-intensity curves with the different imaging modalities. The final diagnosis was confirmed at pathology in all cases. Microvessel density (MVD) was assessed in the surgical specimen using CD34.

RESULTS

The correct assessment of biological behaviour was achieved in all cases by angiosonography (sensitivity of 100%; specificity of 91%) and colour Doppler US (45% sensitivity; 78% specificity). MVD correlated with the biological behaviour.

CONCLUSIONS

Angiosonography is more accurate than colour Doppler US in the correct assessment of biological behaviour of suspicious breast lesions.

Endovascular versus Surgical Preemptive Repair of Forearm Arteriovenous Fistula Juxta-Anastomotic Stenosis: Analysis of Data Collected Prospectively from 1999 to 2004

Surgery is the traditional treatment for juxta-anastomotic stenoses in forearm arteriovenous fistulas (AVF), but percutaneous transluminal angioplasty (PTA) is a suitable alternative. No prospective comparative trials between the two have been reported to date, however. A retrospective analysis of prospectively, concurrently collected data was performed to compare the outcome and cost of surgery and PTA in the preemptive repair of juxta-anastomotic stenosis in lower forearm AVF. Sixty-four AVF with >50% venous juxta-anastomotic stenosis were considered: 21 were treated surgically (11 proximal neo-anastomosis and 10 polytetrafluoroethylene interposition graft) and 43 by PTA. After treatment, AVF were monitored by quarterly ultrasound dilution access blood flow measurement. End points were restenosis and procedure failure rate (re-intervention by another technique or access loss), and determinants were analyzed using Cox hazard model. Initial procedural success was 100% for surgery and 95% for PTA (P = 0.539). Restenosis rate was 0.168 and 0.519 events/AVF-year for surgery and PTA, respectively (P = 0.009). The type of procedure was the only variable that was significantly associated with restenosis, the adjusted relative risk being 2.77-fold higher (95% confidence interval 1.07 to 7.17; P = 0.036) after PTA than surgery. The procedure failure rate was 0.110 and 0.097 events/AVF-year for surgery and PTA, respectively (P = 0.736). The cost profile also was similar for the two procedures. This prospective comparative study confirms a higher restenosis rate after PTA than surgery, but with strict surveillance for restenosis, the two procedures show similar assisted primary patency and cost, suggesting that they should be considered equally valid, complementary alternatives in the preemptive treatment of juxta-anastomotic stenosis in forearm AVF.

Branch duct IPMTs: value of cross-sectional imaging in the assessment of biological behavior and follow-up

Branch duct intraductal papillary mucinous tumors (IPMTs) are increasingly being described and represent a challenge for the physician. Recent imaging modalities, especially computed tomography and magnetic resonance, allow for a correct diagnosis, but IPMTs can manifest with different degrees of cellular atypia so it is very important to be able to establish the biological behavior of the lesion. Sixty-five patients were included in this study: 29 of them underwent surgery, and the other 36 were followed with cross-sectional imaging. Among patients who underwent surgery, 11 had benign lesions and 18 had malignant lesions. Overall sensitivity, specificity, and accuracy in the diagnosis of malignancy for all the cross-sectional imaging techniques were 61%, 81%, and 69%, respectively. Among patients who were followed and had a magnetic resonance cholangiopancreatographic diagnosis of branch duct IPMT with imaging features indicative of benignity, only two showed modifications over the follow-up period. Even considering some important biases (small number of patients and relatively short follow-up), interesting conclusions can be drawn: the imaging diagnosis of malignancy can be trusted, whereas that of benignity cannot be relied upon, but if the signs of malignancy are absent, the slow growth of the lesions justifies watchful follow-up in the correct clinical setting.

US and MRI features of pelvic endometriosis

Endometriosis represents a common and important clinical problem of women of childbearing age. It is a disabling disorder manifesting with pain and infertility. The exact pathogenesis of the disease remains unclear, despite the different theories that have been formulated. The literature on endometriosis is extensive, but often in regard to classic endometrioma. It is surprising that, to the best of our knowledge, the many radiologic features of extraovarian endometriosis have not been well documented thus far. Although ultrasound (US) remains the imaging modality of choice in the radiologic evaluation of female patients with pelvic pain, the role of magnetic resonance imaging (MRI) in the evaluation of abdominal pain is expanding. In the young patient, MRI may be performed if a gynecologic disorder is not suspected at first, especially if US findings are equivocal or the abnormality extends beyond the field of view of the sonographic probe. Moreover, MRI is useful whenever further characterization of pelvic disorder is required. In fact, many causes of pelvic disorders and of endometriosis in particular demonstrate characteristic MRI findings. For these reasons, in this work we describe the protean US and MRI appearances of endometrial foci as encountered in daily experience.

Spiral computed tomography assessment of resectability of pancreatic ductal adenocarcinoma: analysis of results

BACKGROUND

Despite more recent technical advances, single detector spiral computed tomography is still the most widely used imaging technique for the detection and staging of pancreatic adenocarcinoma. Many reports have recently focused on single detector spiral computed tomography imaging findings indicative of unresectability

AIM

To evaluate the ability of single detector spiral computed tomography in the pre-operative staging of ductal adenocarcinoma of the pancreas in selecting surgically resectable versus unresectable cases, considering different parameters (vascular and local infiltration, liver metastases, lymphadenopathy, and peritoneal carcinomatosis).

PATIENTS AND METHODS

A total of 100 patients diagnosed with ductal adenocarcinoma of the pancreas, pathologically verified, and examined with single detector spiral computed tomography were considered. Of these, 63 underwent surgery; 37 were excluded (imaging evidence of unresectability in biopsy-proven adenocarcinomas). Single detector spiral computed tomography studies, performed at the time of surgery, were retrospectively reviewed by two radiologists. The final results were reached by consensus, without being aware of the operation. All prospective clinical readings were also considered, and tabulated.

RESULTS

In the patients undergoing surgery, 44 proved to be unresectable and 19 resectable. Considering the above-mentioned parameters, the prospective assessment of resectability demonstrated a rather low sensitivity (68%), with high specificity (95%). Accordingly, a high positive predictive value (97%) was achieved, while the negative predictive value was 56%. After the retrospective evaluation, the value of sensitivity increased (84%) to the expense of the specificity (84%). Moreover, a positive predictive value of 92.5%, and a negative predictive value of 69.5% were obtained.

CONCLUSIONS

The demonstration of many signs of unresectability of pancreatic ductal adenocarcinoma reported in the literature yields a better sensitivity in the diagnosis, but unfortunately, is associated with an inevitable reduction in specificity.

What preoperative assessment is necessary for insulinomas? Calculating the degree of waste: analysis of 29 cases

In patients affected with insulinomas the preoperative work-up is debated. The success rate of various localisation procedures seems considerably inferior in respect to intraoperative results. Aim of the study is to evaluate our personal experience with this dichotomy. Twenty nine patients with definitive diagnoses of primary hyperinsulinemia from 1985 until June of 2001 were selected. Sensitivity, diagnostic accuracy, positive predictive value and cost of ultrasound (US) (29 pts.), computerised tomography (CT) (29 pts.), magnetic resonance imaging (MRI) (16 pts.), selective angiography (18 pts) and intraoperative ultrasound (IOUS) (18 pts.) in the localisation of neoplasm were evaluated. The presence of neoplasm was verified at operation or at autopsy in 27 cases (93%). The sensitivity of US, CT, MRI and selective angiography was 52%, 44%, 57% and 82%, respectively, with a cost of non-diagnostic studies equal to 422 [symbol: see text]/patient with a comprehensive waste equal to 43.7% of resources utilised. The sensitivity of IOUS and visualisation or physical exam by the surgeon was 100%, 46% and 96%, respectively. In 2 cases where there was a recurrence of symptoms after surgery, the histological exam of the operative specimen did not have evidence of insulinoma tissue. Surgery with the help of IOUS, preceded by only one pre-op diagnostic imaging technique represents the best approach for establishing the diagnosis of and treating insulinomas.

Autoimmune pancreatitis: possibilities of CT characterization

BACKGROUND

Pancreatitis is defined as an inflammatory disease of the pancreas, leading to morphological and pathological changes. Recently, an autoimmune pathogenesis of this disease has been proposed. This type of pancreatitis should be differentiated from other pancreatic diseases, since appropriate therapy is effective and morphological changes and pancreatic function can recover to normal levels.

AIM OF THE STUDY

To assess the possibility of distinguishing autoimmune pancreatitis from other pancreatic diseases with an analogous clinical presentation on the basis of CT findings alone.

METHODS

The CT images of 7 patients with proven autoimmune pancreatitis, along with those of 20 patients with other pancreatic diseases, but with an analogous clinical presentation, were retrospectively evaluated in a blinded fashion by 2 radiologists. In particular, the radiologists had to search for the typical signs of autoimmune pancreatitis. Discordant cases were further analyzed in the presence of a 3rd radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The sensitivity, specificity, positive and negative predictive values of CT were calculated against each of the diseases (autoimmune pancreatitis; other pancreatic diseases), in order to evaluate the diagnostic value of the scan.

RESULTS

After the consensus evaluation, the correct diagnosis was reached in 25/27 (92.5%) cases, with only 2/27 wrong diagnoses (autoimmune pancreatitis diagnosed as another pancreatic disease and vice versa). The sensitivity and specificity of CT against autoimmune pancreatitis were 86 and 95%, respectively. The positive and negative predictive values were 89 and 93%, respectively.

CONCLUSION

Patients with autoimmune pancreatitis demonstrate imaging findings that enable the correct diagnosis by dynamic CT, even in the presence of nonspecific clinical symptoms. The precise classification of the disease is extremely important, since simple steroid therapy then represents the correct treatment, and leads to complete recovery.

Intraductal papillary mucinous tumors of the pancreas: spectrum of CT and MR findings with pathologic correlation

The reports of intraductal papillary mucinous tumors (IPMT) of the pancreas are increasingly more frequent in the literature. The diagnosis by means of cross-sectional imaging of these tumors is not easy, especially in the early stages, when they can mimic an inflammatory disease of the pancreas. Prompt identification of the disease is nevertheless extremely important, especially in the case of tumors originating from the collateral branches, since its recognition can modify the management of the patient, in some cases obviating recourse to surgery.

Nonfunctioning endocrine tumors of the pancreas: possibilities of spiral CT characterization

The aim of this study was to assess the ability of spiral CT to adequately characterize the nonfunctioning endocrine tumors (NFETs) of the pancreas, distinguishing this lesion from the other pancreatic tumors. The spiral CT examinations of 21 cases of histologically proven NFETs, along with those of 29 cases of other pancreatic tumors and tumor-like lesions, were retrospectively reviewed in a blinded fashion by two radiologists, in order to correctly classify the lesions, highlighting the typical signs reported in the literature. Discordant cases were further analyzed in the presence of a third radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The histopathologic examination was considered the gold standard. The sensitivity, specificity, and positive and negative predictive values of CT were calculated. After the consensus evaluation, the correct diagnosis was reached in 72% of cases, with 10% of nonspecific diagnoses of solid pancreatic tumor and 18% of wrong diagnoses. The sensitivity and specificity of spiral CT in identifying NFETs were 66.6 and 82.7%, respectively. The positive and negative predictive values were 73.7 and 77.4%, respectively. In up to 70% of cases the NFET demonstrates a typical aspect of a mass hyperdense in the arterial contrastographic phase eventually associated with hyperdense hepatic metastases in more than half of the patients. This finding does allow the diagnosis of NFET but without certainty indeed, since other tumors can show a similar densitometric behavior and among them particularly the ductal adenocarcinoma. On the other hand, both the solid, hypovascularized NFETs, and the cystic form, cannot be differentiated from the other solid and cystic tumors of the pancreas.

CT features of malignant mucinous cystic tumors of the pancreas

This study is aimed at evaluating which pre-operative findings at CT are prevailingly associated with histologically malignant appearance of mucinous cystic tumor (MCT) of the pancreas. The CT examinations of 52 female patients affected with pathologically proved MCT were retrospectively evaluated by two radiologists, blinded to the histopathological assessment of the biologic behavior (either benign or malignant). A multivariate logistic regression analysis was performed in order to identify the most important features associated with the malignant nature of MCT. Calcifications in the wall and/or in the septa, thick wall, and septations resulted in the most important features associated with malignancy. The simultaneous presence of all these radiological signs constitutes an almost "certain" marker of malignancy, being the risk equal to 0.95, whereas the simultaneous presence of at least two of them entails a risk of malignancy ranging from 0.56 to 0.74, according to the type of morphological features. On the other hand, the absence of the mentioned radiological features entails a negligible risk of malignancy (0.02). Mucinous cystic tumors characterized by multilocular macrocystic architecture, with thick wall and calcifications in the wall and/or the septa, present the highest risk of malignancy, and advocate prompt surgical intervention. When those signs are absent, the probability of malignancy is lower. In this case a non-operative management is possible.

Cystic pancreatic masses: cross-sectional imaging observations and serial follow-up

BACKGROUND

We retrospectively reviewed the imaging features of a series of patients with cystic pancreatic masses, the majority of whom underwent imaging surveillance.

METHODS

Imaging data from 30 patients with known cystic pancreatic masses were reviewed. Nine patients had surgical and/or cytologic classification. Of the 21 who were not operated on, all underwent serial imaging surveillance. Of these, five had corroborative endoscopic retrograde cholangiopancreatography and 16 were followed by only computed tomography and/or magnetic resonance imaging.

RESULTS

In the nonoperated group, mean follow-up time was 30 months (3-144 months). Two patients demonstrated growth, and the remainder remain stable. In the patients who underwent surgery, invasive carcinoma was found in those with lesions larger than 4 cm, involvement of the main pancreatic duct, or visible solid components on the imaging study. Smaller lesions were benign.

CONCLUSION

In patients with suspected cystic pancreatic neoplasms, surveillance might be possible if lesions are smaller than 2.5 cm, spare the main pancreatic duct, and demonstrate no solid components.

Cystic tumours of the pancreas: a review

The detection of a cystic tumour of the pancreas is a challenge which puts not only the surgeon's knowledge and expertise to the test, but also those of the team of radiologists and pathologists with whom he works. The diagnosis of a suspected pancreatic cystic tumour is morphological and is based on modern imaging techniques and, in the case of intraductal papillary mucinous tumours, on endoscopic findings. In the search for the correct preoperative diagnosis, however, it is of fundamental importance to bear in mind the limitations of the various instrumental investigations, and particularly those of fine-needle aspiration cytology. In this light the main morphological and clinicopathological features of serous cystadenomas, mucinous adenomas and adenocarcinomas, intraductal papillary mucinous tumours and papillary cystic and solid tumours are analysed as well as the surgical indications. In fact only the surgeon, on the basis of his knowledge of the patient's medical history and symptoms, will be in a position to determine to which nosological "cystic" entity the morphological findings described belong. A deeper knowledge of the natural history of each of these cystic tumours will help the surgeon formulate the most appropriate treatment indication. Providing the patient's condition fulfills the necessary operability criteria, resection will be mandatory whenever there exists a doubt that the tumour may be malignant or whenever its natural history suggests a malignant potential.

[Serous cystadenoma of the pancreas: imaging findings]

PURPOSE

To present the imaging findings of serous cystadenoma (SCA) and discuss the main problems of differential diagnosis with other cystic pancreatic lesions.

MATERIALS AND METHODS

55 cases of SCA were reviewed; all the lesions proved to be benign at pathology. 35 tumors were evaluated with Ultrasonography (US), 49 with Computed Tomography (CT), and 15 with Magnetic Resonance Imaging (MRI).

RESULTS

Among the patients who underwent either demolitive (47) or derivative (3) interventions, two different morpho-structural patterns were identified: microcystic (37), and oligocystic (13). The diagnosis of SCA, possible in the presence of microcystic pattern, was achieved in 63% of cases by US (22/35), in 63% of cases by CT (31/49), and in 73% of cases by MRI (11/15). In 12 patients evaluated with all the imaging modalities, the combined information allowed a correct diagnosis in 10 cases (83%). The 13 oligocystic tumors were almost always undistinguishable from other cystic masses of the pancreas.

CONCLUSIONS

The diagnosis of SCA can be considered certain if a microcystic pattern is detected. A correct diagnosis is not achievable in the presence of oligocystic architecture. MRI is the best imaging modality in characterizing this tumor.

Duodenal duplication cyst identified with MRCP

We report a case of a stalked cystic duodenal duplication. The lesion, hyperintense on T2-weighted GRE images, maintained the signal intensity after oral administration of a negative contrast agent (Lumirem, Guerbet, Aulnay-Sous-Bois, France), confirming its independence from the duodenal lumen. To our knowledge, this is the first demonstration of duodenal duplication by means of MR cholangiopancreatography.

Afferent loop syndrome presenting as enterolith after Billroth II subtotal gastrectomy: a case report

We present a rare late-onset (after 24 years) complication of gastric surgery with a combination of afferent loop syndrome associated with a large duodenal stone. The patient, who had undergone Billroth II partial gastrectomy for benign ulcer 24 years before, developed abdominal pain in the right upper quadrant, associated with nausea, vomiting, and high grade fever. Abnormal laboratory values included elevated liver function test, suggesting a pressure-related phenomenon. Leukocytosis and a high level of platelets were also found. Only computed tomography and endoscopy of the upper gastrointestinal tract confirmed the diagnosis of a huge stone in the dilated duodenal afferent loop. To our knowledge, a case like this has not been reported previously in the literature.

Reboxetine in the treatment of depression in the elderly: pilot study

Elderly patients are particularly susceptible to the potential side effects of current antidepressants due to agerelated physiologic changes. We report a pilot study to examine the tolerability of increasing doses of reboxetine, a selective noradrenaline reuptake inhibitor (selective NRI), in elderly depressed patients. Twelve elderly female patients (75-87 years) with either major depression or dysthymia received reboxetine titrated to 8 mg/day over a 4-week period. Tolerability was assessed and included the measurement of vital signs. Electrocardiograms were recorded at baseline and on days 14 and 28. Newly emergent signs and symptoms were recorded throughout the study. Efficacy was assessed using four rating scales, including the Clinical Global Impression (CGI) scale and Hamilton Depression Rating Scale (HAM-D). Eleven patients completed the study, nine received the maximal dose of reboxetine 8 mg/day, and two received maximum doses of reboxetine 6 mg/day due to cardiac rhythm changes in week 3. A total of five patients experienced tachycardia (including two with cardiac rhythm changes in week 3). At the end of the study, seven patients were "much" to "very much" improved on the CGI scale with a concomitant decrease in HAM-D total score of 22% to 41%. Reboxetine was well tolerated by the majority of patients and efficacy outweighed side effects in 75% of patients. Reboxetine 4 mg/day, increasing to 6 mg/day on the basis of individual patient tolerability, may be considered as a safe dose range for testing the efficacy and tolerability of reboxetine in long-term controlled clinical trials in elderly patients with depression.

Characterization of cystic tumors of the pancreas: CT accuracy

PURPOSE

The purpose of this work was to evaluate the capabilities of CT to accurately characterize cystic tumors of the pancreas.

METHOD

Two observers retrospectively evaluated the CT exams of 100 cystic masses of the pancreas, with pathological confirmation. The two observers, blinded about clinical information and the final diagnosis, tried to categorize the lesions according to well established morphologic features. Statistical analysis was performed to measure the agreement between each radiologist and the consensus diagnosis and to evaluate the usefulness of certain CT findings in differentiating one type of cystic pancreatic neoplasm from another.

RESULTS

Serous cystadenoma was better diagnosed by CT [Youden misclassification index (Ymi) = 0.72] than mucinous cystic tumor (Ymi = 0.44) and solid pseudopapillary tumor (cystic variant) (Ymi = 0.47).

CONCLUSION

As patients with previous history of pancreatitis were excluded from the study, CT findings allowed correct characterization of only 60% of cystic pancreatic masses. Among the remaining 40%, 15-20% of the wrong diagnoses could not be corrected by means of CT, given the patterns shown by the tumors. In 20-25% of the cases, a nonspecific diagnosis of cystic mass was made.