Early tongue carcinomas (clinical stage I and II): echo-guided three-dimensional diode laser mini-invasive surgery with evaluation of histological prognostic parameters. A study of 85 cases with prolonged follow-up.

The management of patients with early stage (cT1-T2) tongue squamous cell carcinoma without clinicoradiologic evidence of neck node metastasis (cN0) has been widely debated over the last 3 decades and still remains controversial. Nevertheless, the identification of patients with low-stage tumours at high-risk for occult cervical metastases is imperative before planning treatments of primary tumours, as well as that of prognostic markers which may possibly select those patients who may benefit of additional workup after surgery in view of the high metastatic potential of the primary tumour. The pre-surgical evaluation of tongue malignant primary tumour (for assessing lateral and deep margins) along with diode laser surgery (with accurate incision, bleeding-free and with reduced/absent post-surgical complications) may lead to a more conservative but equally decisive surgical treatment, also with a greater patient compliance. We studied 85 consecutive cases of cT1-T2 N0 tongue squamous cell carcinoma who had been managed by the following diagnostic/therapeutic protocol: pre-operative high definition ultrasound examination for the evaluation of size and depth, followed by three-dimensional surgical excision by diode laser (wavelength of 800 ± 10 nm, output power of 8 W in continuous wave, flexible optic fibre of 320 µm in contact mode) and detailed histological analyses of well-established prognostic parameters (tumour grade, thickness, depth, front of infiltration and surgical margins) with statistical analysis. No post-surgical photobiomodulation was performed. Overall, 58.82% of patients were stage I, 18% stage II, and the most frequent histotype was squamous cell carcinoma (97.64%). Large nests invasion pattern was observed in 64 cases, expansive pattern in 9, invasion in single cells in 12; front of invasion involved the muscle in 62 cases, vessels in 6, nerves in 15; peritumoural vascular invasion was assessed in 6 patients and perineural invasion in 15. Selective neck lymphadenectomy was performed in 9 cases, and clinically occult node metastases were detected in two cases. At follow-up, 78 patients (98.73%) were alive and free of disease, one patient experienced tumour-related death, while the remaining 6 died for non-disease-related causes. All the histological prognostic parameters were statistically significant (χ2 test; p = 0.05), thus leading to a prognostic weight classification with a three-tiered stratification. On the bases of these results, the authors maintain that the reported diagnostic/therapeutic protocol, including the pre-operative echo-guided three-dimensional evaluation, the following diode laser mini-invasive surgery for tumour excision and the histological examination along with the proposed three-tiered stratification of histological prognostic parameters may allow proper management of clinical stage I and II early tongue carcinomas.

Diagnostic potential of multidetector computed tomography for characterizing small renal masses.

OBJECTIVES: To assess the potential of CT for characterizing small renal tumors. METHODS: 76 patients with <4 cm renal tumors underwent CT examination. The following parameters were assessed: presence of calcifications, densitometry on unenhanced and enhanced scans, washout percentage, urinary tract infiltration, star-shaped scar, and paradoxical effect. RESULTS: Calcifications were found in 7/56 (12.5%) carcinomas. Clear cell carcinomas were as follows: mean density 183.5 HU (arterial phase), 136 HU (portal phase), and 94 HU (delayed phase), washout 34.3%; chromophobe carcinomas were as follows: mean density 135 HU (arterial phase), 161 HU (portal phase), and 148 HU (delayed phase), washout 28%; papillary carcinomas were as follows: mean density 50.3 HU (arterial phase), 60 HU (portal phase), and 58.1 HU (delayed phase), washout 2.7%. In 2/56 (3.6%) cases urinary tract infiltration was found. Oncocytomas were as follows: mean density 126.5 HU (arterial phase), 147.5 HU (portal phase), and 115.5 HU (delayed phase), washout 28.6%. On unenhanced scans, angiomyolipomas were as follows: density values <30 HU in 12/12 (100%) of cases and on enhanced scans: mean density 78 HU (arterial phase), 128 HU (portal phase), and 80 HU (delayed phase), washout 50%. CONCLUSIONS: Intralesional calcifications and urinary tract infiltration are suggestive for malignancy, with the evidence of adipose tissue for angiomyolipomas and a modest increase in density with a reduced washout for papillary carcinomas. The intralesional density on enhanced scans, peak enhancement, and washout do not seem significant for differentiating clear cell, chromophobe carcinomas, angiomyolipomas, and oncocytomas.

Value of the CT "capsular sign" as a potential indicator of acute adrenal ischemia.

Acute adrenal ischemia represents a rare cause of adrenal insufficiency which should be promptly diagnosed in order to preserve adrenal vitality and function. Our study aims to retrospectively evaluate the diagnostic accuracy of the CT capsular sign as an indicator of adrenal ischemia and its association with vascular involvement. Between January 2013 and January 2014, 69 consecutive patients (47 men, 22 women; mean age 46; range 22-67) with suspected adrenal insufficiency based on clinical and biochemical data underwent 320-row CT examination in our Emergency Department. Written informed consent was obtained for the CT examinations, and the institutional review board approval was obtained for our retrospective study. CT multi-planar images were retrospectively and independently analyzed by two radiologists searching for the patency of adrenal vessels, enlarged adrenals, the presence of the "capsular sign" represented by a peripheral subtle hyperdense line around a hypodense enlarged adrenal, and the presence of any periadrenal inflammatory changes. All CT findings were then compared with the surgical findings (n = 5), follow-up examinations (n = 20), or autopsy (n = 4). Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV), and negative predictive value (NPV) were calculated for the "capsular sign" and were further evaluated by ROC analysis. Acute adrenal ischemia occurred in 29/69 patients (42 %), unilateral in 20, and bilateral in 9. Forty of sixty-nine patients (58 %) had no evidence of adrenal disease on CT. Thrombosis of the main adrenal vein was found in 20/29 (69 %) and non-venous ischemia in 9/29 (31 %). The capsular sign was found in 24/29 patients (83 %). Sensitivity, specificity, DA, PPV, and NPV values of 83, 100, 93, 100, and 89 %, respectively, were obtained. The capsular sign represents a CT indicator of acute adrenal ischemia, with a specificity of 100 % and leading to a prompt diagnosis in the early phase of the disease.

Diabetic mastopathy: a diagnostic challenge in breast sonography.

PURPOSE: Our purpose was to retrospectively evaluate the incidence and morphologic features of diabetic mastopathy in a group of patients with diabetes, searching for specific sonographic characteristics of diabetic mastopathy. METHODS: One hundred twenty diabetic patients underwent breast clinical examination, mammography, and sonography. All detected breast lesions were confirmed histopathologically. RESULTS: Breast lesions were found in 11 of the 120 patients (9%), including two cases of invasive ductal carcinomas and nine cases of diabetic mastopathy. In seven of those nine cases (77%), diabetic mastopathy appeared as a hypoechoic solid mass with irregular margins, inhomogeneous echotexture, and marked posterior shadowing. In the other two cases (23%), it appeared as a mildly inhomogeneous, hypoechoic solid mass. CONCLUSIONS: Diabetic mastopathy is a diagnostic challenge and needs to be suspected in all patients with diabetes mellitus. Imaging features are nonspecific and highly susggestive on breast sonography in most cases. Core-needle biopsy confirmation remains mandatory for a definitive diagnosis.

Contrast-enhanced ultrasound in the diagnosis of hepatocellular carcinoma.

PURPOSE: The American Association for the Study of Liver Diseases and the European Association for the Study of the Liver exclude any role of contrast-enhanced ultrasound (CEUS) in the diagnosis of hepatocellular carcinoma (HCC) while the Italian Association for the Study of the Liver suggests its use for larger HCC. This study evaluated the accuracy of CEUS in comparison with computed tomography (CT) in the diagnosis of HCC and of residual of HCC after treatment. MATERIALS AND METHODS: We retrospectively evaluated 124 patients with 148 HCC nodules: 34 small (≤20 mm) and 114 large nodules (>20 mm). Ninety-three patients underwent treatment [one resection, 23 transcatheter arterial chemoembolisation (TACE), 37 radiofrequency ablation (RFA), 32 TACE/RFA combined with sorafenib]. The diagnosis of HCC on CEUS was confirmed by the typical pattern of arterial enhancement and portal and/or venous phase washout. RESULTS: We performed 90 CEUS for the initial diagnosis of HCC in 85 patients and 107 CEUS for the diagnosis of residual HCC after 1-month treatment in 92 patients. Sensitivity, specificity, positive predictive value, negative predictive value of CEUS and CT in the initial diagnosis of HCC were: 63 vs 92, 100 vs 100, 100 vs 100, 9 vs 25 for small HCC; 77 vs 92, 100 vs 100, 100 vs 100, 13 vs 22 for large HCC. In the diagnosis of residual of HCC, CEUS had a sensitivity of 70 % for small nodules and 76 % for large nodules, with an overall specificity of 100 %. CONCLUSION: CEUS is useful in the initial diagnosis and in the assessment of necrosis after RFA and TACE of HCC nodules.

CT-guided needle biopsy performed with modified coaxial technique in patients with refractory or recurrent lymphomas.

The aim of this study was to evaluate the role of computed tomography (CT)-guided core needle biopsy (CNB) performed by modified coaxial technique as an alternative tool to surgical biopsy in patients with refractory or recurrent lymphomas. Between May 2005 and May 2012, 57 CT-guided CNB of deep lesions were performed in patients with a previous diagnosis of lymphoma and suspected for refractory or recurrent disease. A modified coaxial technique was used in all cases and multiple samples were obtained for histological and immunohistochemical studies. A diagnosis of lymphoma with specification of subtype according to the World Health Organization (WHO) classification was established in 30/57 cases (52.6 %). The previous diagnosis of lymphoma was confirmed in 27/57 patients (47.4 %), whereas histological progression in 3/57 (5.3 %) and other malignant neoplasms in 17/57 (29.8 %) were found. Lymphoma without subtype specification was diagnosed in 6/57 (10.5 %), and no conclusive diagnosis could be established in 4/57 cases (7 %). Overall diagnostic accuracy was 82.5 %. In patients with a final diagnosis of malignant lymphoma, accuracy was 75 %. No complications occurred. Percutaneous CT-guided CNB is a safe, effective and reliable tool in the management of patients with refractory or recurrent lymphomas without superficial lymphadenopathy and can be considered as alternative to surgical sampling.

Standard high-resolution pelvic MRI vs. low-resolution pelvic MRI in the evaluation of deep infiltrating endometriosis.

OBJECTIVE: To compare the capabilities of standard pelvic MRI with low-resolution pelvic MRI using fast breath-hold sequences to evaluate deep infiltrating endometriosis (DIE). METHODS: Sixty-eight consecutive women with suspected DIE were studied with pelvic MRI. A double-acquisition protocol was carried out in each case. High-resolution (HR)-MRI consisted of axial, sagittal, and coronal TSE T2W images, axial TSE T1W, and axial THRIVE. Low-resolution (LR)-MRI was acquired using fast single shot (SSH) T2 and T1 images. Two radiologists with 10 and 2 years of experience reviewed HR and LR images in two separate sessions. The presence of endometriotic lesions of the uterosacral ligament (USL), rectovaginal septum (RVS), pouch of Douglas (POD), and rectal wall was noted. The accuracies of LR-MRI and HR-MRI were compared with the laparoscopic and histopathological findings. RESULTS: Average acquisition times were 24 minutes for HR-MRI and 7 minutes for LR-MRI. The more experienced radiologist achieved higher accuracy with both HR-MRI and LR-MRI. The values of sensitivity, specificity, PPV, NPV, and accuracy did not significantly change between HR and LR images or interobserver agreement for all of the considered anatomic sites. CONCLUSIONS: LR-MRI performs as well as HR-MRI and is a valuable tool for the detection of deep endometriosis extension. KEY POINTS: • High- and low-resolution MRI perform similarly in deep endometriosis evaluation • Low-resolution MRI significantly reduces the duration of the examination • Radiologist experience is fundamental for evaluating deep pelvic endometriosis.

Role of CT in the diagnosis of jejunal-ileal perforations.

PURPOSE: The purpose of this study was to evaluate the computed tomography (CT) signs of free and covered small-bowel perforations and the potential of CT in recognising the aetiology. MATERIALS AND METHODS: Thirty-five patients with surgically proven small-bowel perforation were retrospectively evaluated. Fundamental signs (extraluminal air, solution of continuity) and secondary signs (thickening of the mesentery, free or perilesional fluid, wall thickening) were considered. RESULTS: CT alterations were found in 31/35 (88.6%) patients: extraluminal air (30/35, 85.7%), solution of continuity (11/35, 31.4%), intra-abdominal fluid (27/35, 77.1%), thickening of the mesentery (20/35, 57.1%), and wall thickening (14/35, 40%). In 25/35 cases (71.4%) pneumoperitoneum was detected, associated with secondary signs (23/25, 82%), confirmed as free perforations at surgery. In 5/35 patients (14.2%), peri-intestinal air bubbles and secondary signs were evident, while in 1/35 cases (2.8%) only secondary signs were seen, namely covered perforations. In 4/35 patients (11.4%) with a covered perforation, the CT scan was negative. The nature of the perforations was completely recognisable in 26/31 cases (83.9%), partially identifiable in 4/31 (12.9%), not evident in 1/31 (3.2%). CONCLUSION: CT investigation is essential in the recognition of a small-bowel perforation and in the definition of its nature.

MDCT in the differentiation of adrenal masses: comparison between different scan delays for the evaluation of intralesional washout.

PURPOSE: To evaluate the accuracy of the washout in the differential diagnosis between adenomas and nonadenomas and to compare the obtained results in delayed CT scans at 5, 10 and 15 minutes. METHODS: Fifty patients with adrenal masses were prospectively evaluated. CT scans were performed by using a 320-row MDCT device, before and after injection of contrast material. In 25 cases, delayed scans were performed at 5' and 10' (group 1), while in the remaining 25, at 5' and 15' (group 2). Absolute and relative wash-out percentage values (APW and RPW) were calculated. RESULTS: Differential diagnosis between adenomas and nonadenomas was obtained in 48/50 (96%) cases, with sensitivity, specificity, and accuracy values of 96%, 95%, and 96%, respectively. In group 1, APW and RPW values were, respectively, 69.8% and 67.2% at 5' and 75.9% and 73.5% at 10' for adenomas and 25.1% and 15.8% at 5' and 33.5% and 20.5% at 10' for nonadenomas. In group 2, APW and RPW values were 63% and 54.6% at 5' and 73.8% and 65.5% at 15' for adenomas and 22% and 12.5% at 5' and 35.5% and 19.9% at 15' for nonadenomas. CONCLUSIONS: The evaluation of the wash-out values in CT scans performed at 5', 10', and 15' provides comparable diagnostic results. CT scans performed at 5' are, therefore, to be preferred, since they reduce the examination time and patient discomfort.

Differential diagnosis between benign and malignant ulcers: 320-row CT virtual gastroscopy.

PURPOSE: This study aims to assess the diagnostic accuracy of virtual gastroscopy obtained by 320-row computed tomography (CT) examination in differentiating benign from malignant gastric ulcers (GUs). MATERIALS AND METHODS: 49 patients (30 M, 19 F, mean age 58.6) with endoscopic and histological diagnosis of GU underwent CT examination. A hypotonizing drug was administered and gastric walls were distended by air in order to perform virtual endoscopy. Based on morphological features, GUs were subdivided into benign or malignant forms by two blinded radiologists. Interobserver agreement was evaluated using Cohen's kappa (κ) test. CT results were then compared with endoscopic and histological findings, having the latter as the reference standard. RESULTS: Thirty-five out of 49 patients (71%) were affected by malignant ulcers, while in the remaining 14 cases diagnosis of benign GU was made. Virtual gastroscopy showed diagnostic accuracy, sensitivity, and specificity values of 94%, 91%, and 100%, respectively, in differentiating benign from malignant ulcers. Almost perfect agreement between the two readers was found (κ = 0.86). CONCLUSION: CT virtual gastroscopy improves the identification of GUs and allows differentiating benign from malignant forms.

Diagnosis of colorectal endometriosis: contribution of contrast enhanced MR-colonography.

OBJECTIVE: To investigate the contribution of contrast-enhanced MR-colonography (CE-MR-C) for the diagnosis of intestinal endometriosis. METHODS: One hundred and four women with suspected endometriosis were prospectively enrolled. All patients were subjected to MRI consisting of two phases: pelvic high-resolution MRI (HR-MRI) followed by CE-MR-C after colonic distension using a 1.5-liter water enema and injection of 0.15 ml/kg of 0.5 M gadolinium-DTPA with T1w high-resolution isotropic volume (THRIVE) and balanced turbo field echo (BTFE) images. HR-MRI and CE-MR-C were considered as two datasets, which were independently reviewed by two radiologists with 12 and 2 years' experience respectively. The presence of deep pelvic endometriotic lesions with particular attention to colorectal involvement was recorded. RESULTS: MRI findings correlated with laparoscopy in all cases. Thanks to CE-MR-C images, sensitivity, specificity, PPV, NPV and accuracy for diagnosis of colorectal endometriosis increased from 76%, 96%, 84%, 93% and 91%, to 95%, 97%, 91%, 99% and 97% for the most experienced radiologist and from 62%, 93%, 72%, 89% and 85%, to 86%, 94%, 82%, 96% and 92% for the less experienced radiologist; moreover, the interobserver agreement increased from 0.63 to 0.80 (Cohen's K test). CONCLUSION: CE-MR-C allows easier recognition of colorectal endometriosis and higher interobserver agreement.

Diagnostic accuracy of computed tomographic colonography for the detection of advanced neoplasia in individuals at increased risk of colorectal cancer.

CONTEXT: Computed tomographic (CT) colonography has been recognized as an alternative for colorectal cancer (CRC) screening in average-risk individuals, but less information is available on its performance in individuals at increased risk of CRC. OBJECTIVE: To assess the accuracy of CT colonography in detecting advanced colorectal neoplasia in asymptomatic individuals at increased risk of CRC using unblinded colonoscopy as the reference standard. DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter, cross-sectional study. Individuals at increased risk of CRC due to either family history of advanced neoplasia in first-degree relatives, personal history of colorectal adenomas, or positive results from fecal occult blood tests (FOBTs) were recruited in 11 Italian centers and 1 Belgian center between December 2004 and May 2007. Each participant underwent CT colonography followed by colonoscopy on the same day. MAIN OUTCOME MEASURES: Sensitivity and specificity of CT colonography in detecting individuals with advanced neoplasia (ie, advanced adenoma or CRC) 6 mm or larger. RESULTS: Of 1103 participants, 937 were included in the final analysis: 373 cases in the family-history group, 343 in the group with personal history of adenomas, and 221 in the FOBT-positive group. Overall, CT colonography identified 151 of 177 participants with advanced neoplasia 6 mm or larger (sensitivity, 85.3%; 95% confidence interval [CI], 79.0%-90.0%) and correctly classified results as negative for 667 of 760 participants without such lesions (specificity, 87.8%; 95% CI, 85.2%-90.0%). The positive and negative predictive values were 61.9% (95% CI, 55.4%-68.0%) and 96.3% (95% CI, 94.6%-97.5%), respectively; after group stratification, a significantly lower negative predictive value was found for the FOBT-positive group (84.9%; 95% CI, 76.2%-91.3%; P < .001). CONCLUSIONS: In a group of persons at increased risk for CRC, CT colonography compared with colonoscopy resulted in a negative predictive value of 96.3% overall. When limited to FOBT-positive persons, the negative predictive value was 84.9%.

Diode Laser Photocoagulation of Intraoral and Perioral Venous Malformations After Tridimensional Staging by High Definition Ultrasonography.

Objective: To determine optimal settings for use of diode lasers to treat vascular malformations in the head and neck. Background: Diode lasers are generally accepted as effective tools to treat vascular malformations in the head and neck, yet there are no standardized treatment protocols for this treatment approach. Settings for these lasers, in addition to laser type and size and lesion depth are important variables for designing appropriate treatments for vascular malformations. Materials and methods: Vascular venous malformations (VeMs) were classified into five groups according to high-definition ultrasound measurements of superficial dimensions (<1, 1-3, and >3 cm) and lesion extension depth (≤5, and >5 mm). Using a 800 ± 10 nm diode laser for surgical procedures, we treated lesions by two different approaches: trans-mucous/cutaneous photocoagulation (8 and 12 W pulsed wave for cutaneous and mucosal lesions, respectively) and intralesional photocoagulation using a laser set to 13 W in the pulsed wave modality to treat both cutaneous and mucosal lesions. Results: We treated 158 vascular VeMs. According to preoperative staging, there were 52 lesions in Group A (superficial dimension <1 cm), 28 in Group B1 (superficial dimension from 1 to 3 cm, extension depth ≤5 mm), 16 in Group B2 (superficial dimension from 1 to 3 cm, extension depth >5 mm), 42 in Group C1 (superficial dimension >3 cm, extension depth ≤5 mm), and 12 in Group C2 (superficial dimension >3 cm, extension depth >5 mm). All Group A lesions showed complete healing after a single laser treatment, whereas 7%, 10%, 12%, and 16% of lesions classified in Groups B1, B2, C1, and C2, respectively, required further treatments. Conclusions: The laser settings defined in this study were associated with a reduced number of laser applications needed for effective treatment of vascular VeMs. Moreover, the cooling of irradiated tissues, together with prolonged application of a topical regenerative gel, provided good treatment acceptability, reduced the number of postoperative complications, and promoted faster healing of covering tissues.

Contrast-enhanced multislice pneumo-CT-cystography in the evaluation of urinary bladder neoplasms.

PURPOSE: To evaluate the accuracy of contrast-enhanced multislice CT (MSCT) in the study of urothelial tumors after distension of the bladder with air. MATERIALS AND METHODS: We evaluated 43 consecutive patients with endoscopically proven bladder lesions. After air distension of the bladder, unenhanced pelvic and enhanced abdomino-pelvic scans were obtained with the following protocol: thickness 2.5mm x 4mm, increment 1mm, scan delay 40'' and 7-10 min. For each patient we considered the number, size, aspect (papillary or sessile) and contrast enhancement of lesions. Ureteral involvement and the presence of synchronous lesions in the excretory scan were also evaluated. MPR and virtual endoscopy images were reviewed in all cases. RESULTS: Bladder lesions were visualized in 39/43 cases. Compared to conventional cystoscopy, MSCT recognized single lesions in 31/33 patients, two lesions in 4/6, three in 2/2 and more than five foci in 2/2 patients. A papillary aspect was described in 44 cases while 11 lesions were sessile. Conventional Cystoscopy recognized six more lesions as compared with MSCT (four flat and two small papillary lesions). The detection rate for protruding lesions was 100% (52/52) for lesions>5mm and 60% (3/5%) for lesions<5mm. In four patients hydronephrosis was present, while in one case a synchronous lesion was evident in the renal pelvis. CONCLUSION: Contrast-enhanced MSCT with air distension of the urinary bladder is a safe and complete investigation to evaluate the local stage of bladder cancer and to evaluate the ureteral extension of the tumor, as well as the presence of synchronous lesions.

Endocavitary sonography of early oral cavity malignant tumors.

BACKGROUND: Preoperative staging is crucial for oral cancer management. The purpose of this study was to assess the tumor thickness using ultrasound and to correlate the level of histological infiltration with the tumor superficial extension and lesion thickness. METHODS: Thirty-two subjects affected by oral cavity carcinoma were prospectively evaluated with intraoral ultrasound. The ultrasound sensitivity, the correlation between the ultrasound level of infiltration, and lesion diameters and thickness were assessed. RESULTS: A 91% ultrasound sensitivity was found with no significant correlation between tumor diameter and level of histological infiltration (P >.05). A thickness of <2 mm was associated to tumor extension to the lamina propria, a value of >6 mm to muscular layer infiltration. Lymph adenopathies were identified in 21% of cases, associated to muscular layer infiltration in all cases. CONCLUSION: In the study of early oral cavity tumors, ultrasound is accurate for demonstrating the level of tumor infiltration and contributes to the therapeutic choice.

Magnetic Resonance Colonography May Predict the Need for Bowel Resection in Colorectal Endometriosis.

PURPOSE: To define if MRI findings in patients with deep pelvic endometriosis (DPE) may be predictive for the need of bowel resection. MATERIAL AND METHODS: A retrospective survey of 196 pelvic MRIs of women who received laparoscopic procedures for DPE was carried out. A pelvic MRI was performed in all patients: it consisted in T2w-TSE sequences in axial, sagittal, and coronal planes and T1w and THRIVE sequences in the axial plane; the exam was completed by MR-Colonography. Intestinal lesions were measured in short and long axis and the degree of stenosis was established. A multivariate logistic regression was used to identify the predictors of intestinal resection. RESULTS: 57/196 patients received an intestinal resection. Multivariate logistic regression demonstrated a predictive value of short axis (Odds-Ratio = 2.29, p = 0.011) and stenosis (Odds-Ratio = 1.20, p = 0.003). ROC analysis showed that a cut-off value of 11 mm for the short axis and 30% for the stenosis may correctly classify, respectively, 96,94% (sensitivity 92,9% and specificity 98,56%) and 97,96% (sensitivity 94,74% and specificity 99,3%) of the cases. CONCLUSION: The presence of an endometriotic rectal nodule > 11 mm in short axis causing a stenosis > 30% in pelvic MRI reliably predicts the need of a rectal resection.

Hereditary haemorrhagic teleangiectasia: diagnostic imaging of visceral involvement.

Hereditary Haemorrhagic Telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is an autosomal-dominant vascular disease characterised by mucocutaneous or visceral angiodysplastic lesions (telangiectases and arteriovenous malformations), which may be widely distributed throughout the cardiovascular system. Its diagnosis is based on clinical criteria. Liver, lungs and brain, in order of prevalence, are the most frequently involved visceral districts of the body other than skin and nasal mucosa. Liver involvement is frequent and characterised by the presence of intrahepatic shunts, disseminated intraparenchymal telangiectases and other vascular lesions. Although it is usually asymptomatic, congestive cardiac failure, portal hypertension, portosystemic encephalopathy, cholangitis or atypical cirrhosis are possible complications. Pulmonary arteriovenous malformations involve more than one third of HHT patients and can consist of diffuse telangiectases or high-flow low-pressure shunts between pulmonary arteries and veins. Pulmonary involvement can cause serious complications: hypoxaemia, pulmonary or pleural hemorrhage, paradoxical embolism into cerebral circulation. Various types of cerebrovascular malformations can affect HHT patients and the most common are arteriovenous malformations, consisting of one or more feeding arteries connected to one or more draining veins. Diagnostic imaging has a fundamental role in detecting the alterations involving these various districts in the body. The possibility to perform fast and complete studies and to provide high quality multiplanar and angiographic reconstructions, gives multi-detector row helical computed tomography and magnetic resonance the ability to detect and characterise the complex anatomo-pathological alterations typical of HHT. Ultrasonography seems to be the best screening modality for hepatic and pulmonary involvement.

Abbreviated Combined MR Protocol: A New Faster Strategy for Characterizing Breast Lesions.

BACKGROUND: The use of an abbreviated magnetic resonance (MR) protocol has been recently proposed for cancer screening. The aim of our study is to evaluate the diagnostic accuracy of an abbreviated MR protocol combining short TI inversion recovery (STIR), turbo-spin-echo (TSE)-T2 sequences, a pre-contrast T1, and a single intermediate (3 minutes after contrast injection) post-contrast T1 sequence for characterizing breast lesions. MATERIALS AND METHODS: A total of 470 patients underwent breast MR examination for screening, problem solving, or preoperative staging. Two experienced radiologists evaluated both standard and abbreviated protocols in consensus. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for both protocols were calculated (with the histological findings and 6-month ultrasound follow-up as the reference standard) and compared with the McNemar test. The post-processing and interpretation times for the MR images were compared with the paired t test. RESULTS: In 177 of 470 (38%) patients, the MR sequences detected 185 breast lesions. Standard and abbreviated protocols obtained sensitivity, specificity, diagnostic accuracy, PPV, and NPV values respectively of 92%, 92%, 92%, 68%, and 98% and of 89%, 91%, 91%, 64%, and 98% with no statistically significant difference (P < .0001). The mean post-processing and interpretation time were, respectively, 7 ± 1 minutes and 6 ± 3.2 minutes for the standard protocol and 1 ± 1.2 minutes and 2 ± 1.2 minutes for the abbreviated protocol, with a statistically significant difference (P < .01). CONCLUSION: An abbreviated combined MR protocol represents a time-saving tool for radiologists and patients with the same diagnostic potential as the standard protocol in patients undergoing breast MRI for screening, problem solving, or preoperative staging.

Breast MRI background parenchymal enhancement (BPE) correlates with the risk of breast cancer.

OBJECTIVES: To investigate whether background parenchymal enhancement (BPE) and breast cancer would correlate searching for any significant difference of BPE pattern distribution in case of benign or malignant lesions. METHODS: 386 patients, including 180 pre-menopausal (group 1) and 206 post-menopausal (group 2), underwent MR examination. Two radiologists evaluated MR images classifying normal BPE as minimal, mild, moderate or marked. The two groups of patients were subdivided into 3 categories based on MRI findings (negative, benign and malignant lesions). The distribution of BPE patterns within the two groups and within the three MR categories was calculated. The χ2 test was used to evaluate BPE type distribution in the three patient categories and any statistically significant correlation of BPE with lesion type was calculated. The Student t test was applied to search for any statistically significant difference between BPE type rates in group 1 and 2. RESULTS: The χ2 test demonstrated a statistically significant difference in the distribution of BPE types in negative patients and benign lesions as compared with malignant ones (p<0.05). A significantly higher prevalence of moderate and marked BPE was found among malignant lesions (group 1: 32% and 42%, respectively; group 2: 31% and 46%, respectively) while a predominance of minimal and mild BPE among negative patients (group 1: 60% and 36%, respectively; group 2: 68% and 32%, respectively) and benign lesions (group 1: 54% and 38%, respectively; group 2: 75% and 17%, respectively) was found. The Student t test did not show a statistically significant difference between BPE type rates in group 1 and 2 (p>0.05). CONCLUSION: Normal BPE could correlate with the risk of breast cancer being such BPE patterns as moderate and marked associated with patients with malignant lesions in both pre and post-menopausal women.

Supine breast US: how to correlate breast lesions from prone MRI.

OBJECTIVE: To evaluate spatial displacement of breast lesions from prone MR to supine ultrasound positions, and to determine whether the degree of displacement may be associated with breast density and lesion histotype. METHODS: 380 patients underwent breast MR and second-look ultrasound. The MR and ultrasound lesion location within the breast gland, distances from anatomical landmarks (nipple, skin and pectoral muscle), spatial displacement (distance differences from the landmarks within the same breast region) and region displacement (breast region change) were prospectively evaluated. Differences between MR and ultrasound measurements, association between the degree of spatial displacement and both breast density and lesion histotypes were calculated. RESULTS: In 290/380 (76%) patients, 300 MR lesions were detected. 285/300 (95%) lesions were recognized on ultrasound. By comparing MR and ultrasound, spatial displacement occurred in 183/285 (64.3%) cases while region displacement in 102/285 (35.7%) cases with a circumferential movement along an arc centred on the nipple, having supine ultrasound as the reference standard. A significant association between the degree of lesion displacement and breast density was found (p < 0.00001) with a significant higher displacement in case of fatty breasts. No significant association between the degree of displacement and lesion histotype was found (p = 0.1). CONCLUSION: Lesion spatial displacement from MRI to ultrasound may occur especially in adipose breasts. Lesion-nipple distance and circumferential displacement from the nipple need to be considered for ultrasound lesion detection. ADVANCES IN KNOWLEDGE: Second-look ultrasound breast lesion detection could be improved by calculating the lesion-nipple distance and considering that spatial displacement from MRI occurs with a circumferential movement along an arc centred on the nipple.