CT imaging findings of abdominopelvic vascular compression syndromes: what the radiologist needs to know.

Abdominopelvic vascular compression syndromes include a variety of uncommon conditions characterized by either extrinsic compression of blood vessels by adjacent anatomical structures (i.e., median arcuate ligament syndrome, nutcracker syndrome, May-Thurner syndrome) or compression of hollow viscera by adjacent vessels (i.e., superior mesenteric artery syndrome, ureteropelvic junction obstruction, ureteral vascular compression syndromes, portal biliopathy). These syndromes can be unexpectedly diagnosed even in asymptomatic patients and the predisposing anatomic conditions can be incidentally discovered on imaging examinations performed for other indications, or they can manifest with atypical abdominal symptoms and acute complications, which may lead to significant morbidity if unrecognized. Although computed tomography (CT) is an accurate noninvasive technique for their detection, the diagnosis remains challenging due to the uncommon clinical presentation and often overlooked imaging features. Dynamic imaging may be performed in order to evaluate patients with inconstant symptoms manifesting in a specific position. The purposes of this paper are to review the CT imaging findings of abdominopelvic vascular compression syndromes, correlating with anatomical variants and to provide key features for the noninvasive imaging diagnosis.

Intravenous Contrast Agent in Abdominal CT: Is It Really Needed to Identify the Cause of Bowel Obstruction? Proof of Concept.

BACKGROUND: To compare sensitivity of unenhanced computed tomography (CT) and contrast-enhanced CT for the identification of the etiology of bowel obstruction. MATERIALS AND METHODS: We retrospectively evaluated abdominal CT scans of patients operated for bowel obstruction from March 2013 to October 2017. Two radiologists evaluated CT scans before and after contrast agent in two reading sessions. Then, we calculated sensitivity of CT in the diagnosis of bowel obstruction and determined in which cases the etiology of bowel obstruction was detected on both unenhanced and enhanced CT or on enhanced CT only. The reference standard was defined as the final diagnosis obtained after surgery. RESULTS: Eighteen patients (mean age 72 ± 15 years, age range 37-88 years) were included in the study. Sensitivity of unenhanced CT and enhanced CT was not significantly different in either small bowel obstruction (64%, 7/11 patients vs. 73%, 8/11 patients; P = 0.6547) or large bowel obstruction (71%, 5/7 patients vs. 100%, 7/7 patients; P = 0.1410). Adhesions were identified on unenhanced CT as the etiology of small bowel obstruction in 80% (4/5) of patients. Tumors were identified on unenhanced CT as the etiology of large bowel obstruction in 67% (4/6) of patients. CONCLUSION: In the diagnosis of small bowel obstruction due to adhesions with normal bowel wall thickening and when a neoplasm is identified as the etiology of large bowel obstruction on unenhanced CT, an intravenous contrast agent may be avoided for the identification of the etiology. In remaining cases, contrast agent is still recommended.

Role of apparent diffusion coefficient values in prostate diseases characterization on diffusion-weighted magnetic resonance imaging.

BACKGROUND: To evaluate if normal and pathological prostate tissue can be distinguished by using apparent diffusion coefficient (ADC) values on magnetic resonance imaging (MRI) and to understand if it is possible to differentiate among pathological prostate tissues using ADC values. METHODS: Our population consisted in 81 patients (mean age 65.4 years) in which 84 suspicious areas were identified. Regions of interest were placed over suspicious areas, detected on MRI, and over areas with normal appearance, and ADC values were recorded. Statistical differences between ADC values of suspicious and normal areas were evaluated. Histopathological diagnosis, obtained from targeted biopsy using MRI-US fusion biopsies in 39 patients and from prostatectomy in 42 patients, were correlated to ADC values. RESULTS: Histopathological diagnosis revealed 58 cases of prostate cancer (PCa), 19 patients with indolent PCa (Gleason Score ≤6) and 39 patients with clinically significant PCa (Gleason Score ≥7), 16 of high-grade prostatic intraepithelial neoplasia (HG-PIN) and 10 of atypical small acinar proliferation (ASAP). Significant statistical differences between mean ADC values of normal prostate tissue versus PCa (P<0.00001), HG-PIN (P<0.00001) and ASAP (P<0.00001) were found. Significant differences were observed between mean ADC values of PCa versus HG-PIN (P<0.00001) and ASAP (P<0.00001) with many overlapping values. Differences between mean ADC values of HG-PIN versus ASAP (P=0.015) were not significant. Significant differences of ADC values were also observed between patients with indolent and clinically significant PCa (P<0.00001). CONCLUSIONS: ADC values allow differentiation between normal and pathological prostate tissue and between indolent and clinically significant PCa but do not allow a definite differentiation between PCa, HG-PIN, and ASAP.

Glypican-3 and Hep Par-1 are Useful Biomarkers in the Cytologic Assessment of Ascites.

Till date, the utility of cytologic assessment of ascites for the identification of hepatocellular carcinoma (HCC) cells is still debated and the usefulness of immunocytochemistry for glypican-3 (GPC3) and Hep Par-1 in this setting has not been reported. Liquid-based cytology of ascitic fluid of 28 cirrhotic patients was performed and the spots obtained were stained with hematoxylin and eosin, papanicolau, and with GPC3 and Hep Par-1 antibodies. GPC3 and Hep Par-1 antibodies stained positively the atypical cells in the ascites of 2 patients with HCC showing an exophytic growth pattern. The specimens of the patients with nonexophytic HCC, other non-HCC cancers, or cirrhosis stained negatively. We hypothesize a relationship with the exophytic growth of the tumor. Thus, GPC3 and Hep Par-1 are useful in the cytologic assessment of peritoneal effusions to distinguish mesothelial cells and neoplastic non-HCC cells from HCC cells, presence of which, however, represent a very rare event. This is the first study in which GPC3 and Hep Par-1 immunostaining has been used in the cytologic assessment of HCC ascites.

Gadoxetic acid-enhanced MRI of transient hepatic enhancement differences: Another cause of hypointense observation on hepatobiliary phase.

PURPOSE: To retrospectively determine the frequency, natural history and factors associated with the presence of transient hepatic enhancement difference showing hypointensity on hepatobiliary phase images of gadoxetic acid-enhanced MRI. MATERIALS AND METHODS: Gadoxetic acid-enhanced MRI of 125 patients (91 men; 34 women) with transient hepatic enhancement difference were retrospectively reviewed. Three readers qualitatively and quantitatively evaluated MR imaging features and evolution at follow up. The Chi-square test, Fisher's exact test and Kruskall-Wallis rank test were used for statistical analysis. RESULTS: Transient hepatic enhancement difference were hypointense on hepatobiliary phase images in 20 of 125 cases (16%). At univariate analysis there was association with wedge-shape morphology (p < 0.001), size ≥21 mm (p < 0.001), hyperintensity on T2-weighted imaging (p < 0.001), restricted diffusion (p < 0.001) and previous treatment (p < 0.005). At multivariate analysis, the following factors were associated: previous treatment (p < 0.05), hyperintensity on T2-weighted imaging (p < 0.001) and size ≥21 mm (p < 0.001). Of 12 patients with hypointense transient hepatic enhancement difference on hepatobiliary phase images who had follow-up MRI, nine showed reduction in size. CONCLUSION: Transient hepatic enhancement difference observations showing hypointensity on hepatobiliary phase images of gadoxetic acid-enhanced MRI are not infrequent and may shrink at follow-up. They are more likely associated with size ≥21 mm, hyperintensity on T2-weighted images and previous treatment of adjacent tumor.

Diffuse Liver Diseases: Role of imaging.

Nowadays, the most common imaging techniques allow to study focal liver lesions with high diagnostic accuracy but a relatively recent emerging field of interest is represented by diffuse liver disease. They include a variegated series of storage and metabolic pathologies (ie, iron overload disorders and steatosis) requiring a precise diagnosis not always possible at imaging due to the overlapping of findings at conventional ultrasound, CT, or MR studies. In recent years, several imaging tecniques and specific softwares have been developed, especially for ultrasound and MR imaging, in order to identify different parameters useful in the noninvasive recognition and follow-up of these diffuse processes involving the liver. The aim of this article is to describe the most common and useful imaging findings of the most common and uncommon diffuse liver diseases illustrating the newest imaging technologies and developments at our disposal with corresponding advantages, limitations, and pitfalls.

Imaging features of pancreatic metastases: A comparison with pancreatic ductal adenocarcinoma.

PURPOSE: To compare imaging features of pancreatic metastases (PM) with those of pancreatic ductal adenocarcinomas (PDAC). METHODS: CT and MR scans of 24 patients with 54 PM and 30 patients with PDAC were reviewed to evaluate the imaging features, which were compared by using a Chi square test. RESULTS: We found a statistically significant difference between PM and PDAC based on location (P < 0.001), margins (P < 0.001), arterial enhancement (P = 0.004), rim enhancement (P < 0.001), pancreatic duct dilatation (P = 0.01), common bile duct dilatation (P = 0.003), vascular involvement (P = 0.02), parenchymal atrophy (P < 0.001), peripancreatic fluid (P = 0.03). CONCLUSION: Imaging features might be helpful to differentiate PM from PDAC.

Hyaline fibromatosis syndrome (juvenile hyaline fibromatosis): whole-body MR findings in two siblings with different subcutaneous nodules distribution.

Hyaline fibromatosis syndrome (juvenile hyaline fibromatosis) is a rare, progressive, autosomal recessive disorder whose main hallmark is the deposition of amorphous hyaline material in soft tissues, with an evolutionary course and health impairment. It may present involvement of subcutaneous or periskeletal soft tissue, or may develop as a visceral infiltration entity with poor prognosis. Very few radiological data about this inherited condition have been reported, due to the extreme rarity of disease. We herein present a case of two siblings, affected by different severity of the disease, with different clinical features. They were examined by whole-body MR (WBMR) in order to assess different lesions localization, to rule out any visceral involvement and any other associated anomalies and to define patients' management.

Swallowing impairment in neurologic disorders: the role of videofluorographic swallowing study.

Patients with neurologic diseases almost inevitably develop various degrees of swallowing disorders during their life. Dysphagia is one of the main negative prognostic factors in this class of patients, leading to severe morbidity (i.e. aspiration pneumonia, dehydration, malnutrition, and life quality deterioration) and to a noticeable increase in public health spending. Videofluorographic swallowing study is considered the gold standard technique for swallowing impairment assessment. It is aimed at early identification of the risk of aspiration, definition of the kind and grade of dysphagia, and an indication to suspend oral nutrition and adopt other feeding strategies, and define when the patient is able to return to physiological nutrition. Every radiologist should be familiar with the main videofluorographic swallowing features in neurological patients, not only because early diagnosis of deglutition disorders widely improves their prognosis, but also because customising feeding strategies has a great impact on patients' quality of life.

Comparison of US Strain Elastography and Entero-MRI to Typify the Mesenteric and Bowel Wall Changes during Crohn's Disease: A Pilot Study.

PURPOSE: To evaluate and compare the mesenteric and bowel wall changes during Crohn's disease (CD) on ultrasonography (US) Strain Elastography (SE) and Enterography Magnetic Resonance Imaging (E-MRI). METHODS: From July 2014 to September 2016, 35 patients with ileocolonoscopy diagnosis of CD were prospectively examined with E-MRI and in the same time with US and SE. RESULTS: A total of 41 affected bowel segments and 35 unaffected bowel segments in 35 patients were evaluated. US-SE color-scale coding showed a blue color pattern in the fibrotic mesentery and bowel wall in 15 patients and a green color pattern in the edematous ones in 20 patients. The signal of the bowel wall and mesenteric fat was iso/hypointense on T2-weighted sequence in the fibrotic pattern (23/35 and 12/35 patients) and hyperintense in the edematous pattern (12/35 and 23/35 patients). Mean ADC values were, respectively, 2,58 ± 0,33 × 10-3 for the fibrotic mesentery and 2,14 ± 0,28 × 10-3 for edematous one. There was a statistical correlation between US-SE color-scale and T2 signal intensity and between the US-SE color-scale and ADC maps. CONCLUSIONS: US-SE, ADC, and signal intensity on T2-weighted sequences on MR prove to be useful tools for the evaluation of CD pattern.

Role of Densitometric Criteria in Evaluation of Effectiveness of Antiangiogenic Therapies in Metastatic Colorectal Cancer: An Italian Clinical Experience.

BACKGROUND/AIM: To evaluate the role of densitometric criterion using the Choi Criteria in the assessment of the response to antiangiogenic treatments of metastatic colorectal cancer (mCRC) compared to the RECIST criteria. PATIENTS AND METHODS: Fifty-four patients (mean age=50.6 years) affected by advanced colorectal cancer and with hepatic and possibly peritoneal and pulmonary metastases, that can be treated with bevacizumab, were prospectively evaluated by computerized tomography (CT) scan. Metastases were also evaluated by CT in one-dimensional form according to RECIST. RESULTS: Results show that in 58% of analyzed cases, stable disease according to RECIST coincided with stable disease according to the CHOI criteria, whereas in 42% of analyzed cases disease progression according to RECIST corresponded to stable disease or even partial response according to CHOI criteria. CONCLUSION: By using the densitometric criterion with CHOI criteria, the evaluation of the response to antiangiogenic treatment of mCRC is partially different compared to RECIST criteria.

The Videofluorographic Swallowing Study in Rheumatologic Diseases: A Comprehensive Review.

Autoimmune connective tissue diseases are a heterogeneous group of pathologies that affect about 10% of world population with chronic evolution in 20%-80%. Inflammation in autoimmune diseases may lead to serious damage to other organs including the gastrointestinal tract. Gastrointestinal tract involvement in these patients may also due to both a direct action of antibodies against organs and pharmacological therapies. Dysphagia is one of the most important symptom, and it is caused by failure of the swallowing function and may lead to aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction. The videofluorographic swallowing study is a key diagnostic tool in the detection of swallowing disorders, allowing to make an early diagnosis and to reduce the risk of gastrointestinal and pulmonary complications. This technique helps to identify both functional and structural anomalies of the anatomic chain involved in swallowing function. The aim of this review is to systematically analyze the basis of the pathological involvement of the swallowing function for each rheumatological disease and to show the main features of the videofluorographic study that may be encountered in these patients.

Swallowing disorders after thyroidectomy: What we know and where we are. A systematic review.

INTRODUCTION: Dysphagia and hoarseness are possible complications that can be observed in patients undergoing thyroidectomy or other neck surgery procedures. These complaints are usually related to superior and inferior laryngeal nerves dysfunction, but these can appear even after uncomplicated surgical procedure. METHODS: We reviewed the current literature available on MEDLINE database, concerning the swallowing disorders appearing after the thyroidectomy. The articles included in the review reported pathophysiology and diagnostic concerns. RESULTS: Twenty articles were selected for inclusion in the review. Depends on the possible causes of the difficulty swallowing (related to nerve damage or appearing after uncomplicated thyroidectomy), different types of diagnostic procedures could be used to study patient discomfort, as well as intraoperative nerve monitoring, fiber optic laryngoscopy, endoscopy, pH monitoring, esophageal manometry and videofluorography. Among all these procedures, videofluorography is considered the gold standard to evaluate the entire swallowing process, since that allows a real-time study of all the three phases of swallowing: oral phase, pharyngeal phase and esophageal phase. CONCLUSION: The diagnostic procedures described can help to identify the mechanisms involved in swallowing disorders, with the aim to choose the best therapeutic option. More studies are needed for understanding the causes of the dysphagia appearing after thyroidectomy.

Detection of liver metastases in cancer patients with geographic fatty infiltration of the liver: the added value of contrast-enhanced sonography.

PURPOSE: The aim of this study is to assess the role of contrast-enhanced ultrasonography (CEUS) in the detection of liver metastases in cancer patients with geographic liver fatty deposition on greyscale ultrasonography (US). METHODS: Thirty-seven consecutive cancer patients (24 women and 13 men; age, 33 to 80 years; mean, 58.1 years) with geographic liver fatty deposition, but without any detectable focal liver lesion on greyscale US, underwent sulphur hexafluoride-enhanced US. Two readers reported by consensus the presence, size, and location of any detected lesion. All patients underwent magnetic resonance imaging (MRI) as a confirmatory study. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and accuracy were calculated. RESULTS: Seven focal liver lesions (size, 4 to 10 mm; mean, 6.1 mm) were detected in 4/37 patients (10.8%): four metastases (size, 5 to 10 mm; mean, 6.7 mm) were detected both by CEUS and MRI, with one hemangioma and two cysts (size range, 4 to 6 mm; mean, 5.3 mm) detected by MRI only. In 1/37 patients (2.7%), CEUS misdiagnosed geographic fatty change as three metastases. In 32/37 patients (86.5%), no lesions were detected. Sensitivity, specificity, PPV, NPV, and accuracy of CEUS were 100% (95% confidence Interval [CI], 1.000 to 1.000), 97.1% (95% CI, 0.914 to 1.027), 75%, 100%, and 97.3%, respectively. No statistically significant differences were found between CEUS and MRI in the detection of focal liver lesions (P=0.480), whereas both of them performed better than baseline US (P<0.001). CONCLUSION: CEUS improves the detection of liver metastases in cancer patients with geographic liver fatty deposition on greyscale US.

Hamartoma of the spleen (splenoma) with calcifications in a child with beta-thalassemia: A case report.

Splenic hamartoma (or splenoma) is a rare, benign, vascular tumor, often incidentally found at imaging, surgery or autopsy. Albeit usually asymptomatic and rare in children, when it occurs in the pediatric population it is more commonly symptomatic. We report a case of a 15-year-old girl with iron-deficiency anemia and beta-thalassemia, who had a large (10 × 8 × 7 cm) splenic lesion with calcifications, incidentally found during follow-up for splenomegaly and histologically characterized as hamartoma with calcified areas. The association of hamartoma and hematological disorders is a very unusual condition in children.