ESR Essentials: image guided drainage of fluid collections-practice recommendations by the Cardiovascular and Interventional Radiological Society of Europe.

This ESR Essentials article intends to provide detailed, step-by-step, information on the role of imaging in the diagnosis, procedural management, and follow-up of patients with fluid collections. Evidence-based medicine recommendations for the positioning of percutaneous drainages and/or for diagnostic/therapeutic aspiration of fluid collections are provided. Although medical history, clinical symptoms, physical examination, and laboratory tests can raise suspicions regarding a collection, an imaging assessment is usually necessary for the diagnosis. Radiologists can easily identify fluid collections that are clinically suspected by using a wide range of imaging modalities, such as ultrasound, CT, MRI, and cone-beam CT. Consequently, these imaging methods (either alone or combined), can be used to aspirate the collection or for the placement of a drainage catheter. The choice of imaging technique to be used is influenced by the location of the collection, operator preference, size, and content of the collection. In addition, it is of utmost importance to underline the role of the interventional radiologist in the management and follow-up of patients with percutaneous drains, in collaboration with surgeons, clinicians, and diagnostic radiologists. KEY POINTS: Indications for percutaneous imaging-guided drainage are supported by clinical findings, laboratory tests, and pre-procedural imaging. Deciding between aspiration or drain insertion should follow patient assessment and fluid collection characterization. The interventional radiologist should be part of the entire patient care process including follow-up.

Optimization of window settings for coronary arteries assessment using spectral CT-derived virtual monoenergetic imaging.

PURPOSE: To determine the optimal window setting for virtual monoenergetic images (VMI) reconstructed from dual-layer spectral coronary computed tomography angiography (DE-CCTA) datasets. MATERIAL AND METHODS: 50 patients (30 males; mean age 61.1 ± 12.4 years who underwent DE-CCTA from May 2021 to June 2022 for suspected coronary artery disease, were retrospectively included. Image quality assessment was performed on conventional images and VMI reconstructions at 70 and 40 keV. Objective image quality was assessed using contrast-to-noise ratio (CNR). Two independent observers manually identified the best window settings (B-W/L) for VMI 70 and VMI 40 visualization. B-W/L were then normalized with aortic attenuation using linear regression analysis to obtain the optimized W/L (O-W/L) settings. Additionally, subjective image quality was evaluated using a 5-point Likert scale, and vessel diameters were measured to examine any potential impact of different W/L settings. RESULTS: VMI 40 demonstrated higher CNR values compared to conventional and VMI 70. B-W/L settings identified were 1180/280 HU for VMI 70 and 3290/900 HU for VMI 40. Subsequent linear regression analysis yielded O-W/L settings of 1155/270 HU for VMI 70 and 3230/880 HU for VMI 40. VMI 40 O-W/L received the highest scores for each parameter compared to conventional (all p < 0.0027). Using O-W/L settings for VMI 70 and VMI 40 did not result in significant differences in vessel measurements compared to conventional images. CONCLUSION: Optimization of VMI requires adjustments in W/L settings. Our results recommend W/L settings of 1155/270 HU for VMI 70 and 3230/880 HU for VMI 40.

DWI ratios: New indexes for Crohn's disease activity at magnetic resonance enterography?

BACKGROUND: The aim of the study was to provide radiologists and clinicians a rapid tool for assessment of intestinal inflammation in Crohn's disease (CD) patients through quantification of diffusion-weighted imaging (DWI) signal intensity while performing magnetic resonance enterography (MRE). MATERIALS AND METHODS: A monocentric retrospective study was conducted between September 2018 and July 2021 on CD patients who underwent MRE. Two radiologists measured signal intensity on DWI scans at the highest b-value (800 s/mm2) within pathologic intestinal walls, lymph nodes, spleen and psoas muscle and calculated the relative ratios. Spearman, Mann-Whitney and Jonckheere-Terpstra tests were applied for estimating correlation among ratios, significant differences between the two patient groups and determining the trend in relation to endoscopic classes. Wilcoxon's and Cronbach's alpha tests were employed for comparison of DWI measurements and ratios between the two observers. RESULTS: Fifty-nine patients were enrolled in the study. In the non-surgical group, correlation has been found among Simple Endoscopic Score for Crohn's Disease (SES-CD) classes and the different ratios: bowel/spleen (p = 0.034), bowel/psoas (p = 0.008) and bowel/lymph node (p = 0.010). Within the surgical group, positive correlation was found only between bowel/lymph node ratio and bowel/psoas ratio (p = 0.014). The J-T test demonstrated an increasing monotonic trend for bowel/psoas ratio and bowel/lymph node ratio and SES-CD classes. Inter-reader evaluation demonstrated no statistical differences for DWI measurements and high degree of concordance for the final ratios. CONCLUSION: DWI ratios correlate with endoscopic classes in non-surgical patients and have inter-observer reproducibility.

Virtual monoenergetic dual-layer dual-energy CT images in colorectal cancer: CT diagnosis could be improved?

PURPOSE: To compare conventional CT images and virtual monoenergetic images (VMI) at dual-layer dual-energy CT (dlDECT) in patients with colorectal cancer (CRC) through quantitative analysis and to investigate the added value of VMI. MATERIAL AND METHODS: Sixty-six consecutive patients with histologically documented CRC and available VMI reconstructions were retrospectively investigated. Subsequently, forty-two patients, without any colonic disease at colonoscopy, were selected as control group. Conventional CT images and VMI reconstructions at energy levels ranging from 40 (VMI40) to 100 keV (VMI100) in 10 keV increments, were obtained from the late arterial phase. First, signal-to-noise (SNR) and contrast-to-noise (CNR) ratios were obtained to select the best VMI reconstruction. Finally, the diagnostic accuracy of conventional CT and VMI40 in late arterial phase was evaluated. RESULTS: On quantitative analysis, SNR and CNR were higher for VMI40 (19.5 ± 7.7 and 11.8 ± 6.2, respectively) with statistically significant differences compared to conventional CT (P < 0.05) and all the other VMI reconstructions (P < 0.05), except for VMI50 (P > 0.05). The addition of VMI40 to conventional CT images significantly improved the area under the curve (AUC) for the diagnosis of CRC, increasing it from 0.875 to 0.943 for reader 1 (P < 0.05) and from 0.916 to 0.954 for reader 2 (P < 0.05). The improvement was greater in the less experienced radiologist (0.068) compared to the more experienced one (0.037). CONCLUSION: VMI40 has showed the highest quantitative image parameters. Furthermore, the use of VMI40 can lead to a significant improvement in the diagnostic performance for detecting CRC.

Locoregional Therapies and Remodeling of Tumor Microenvironment in Pancreatic Cancer.

Despite the advances made in treatment, the prognosis of pancreatic ductal adenocarcinoma (PDAC) remains dismal, even in the locoregional and locally advanced stages, with high relapse rates after surgery. PDAC exhibits a chemoresistant and immunosuppressive phenotype, and the tumor microenvironment (TME) surrounding cancer cells actively participates in creating a stromal barrier to chemotherapy and an immunosuppressive environment. Recently, there has been an increasing use of interventional radiology techniques for the treatment of PDAC, although they do not represent a standard of care and are not included in clinical guidelines. Local approaches such as radiation therapy, hyperthermia, microwave or radiofrequency ablation, irreversible electroporation and high-intensity focused ultrasound exert their action on the tumor tissue, altering the composition and structure of TME and potentially enhancing the action of chemotherapy. Moreover, their action can increase antigen release and presentation with T-cell activation and reduction tumor-induced immune suppression. This review summarizes the current evidence on locoregional therapies in PDAC and their effect on remodeling TME to make it more susceptible to the action of antitumor agents.

Damage Control Interventional Radiology: The bridge between non-operative management and damage control surgery.

Traumatic injuries continue to be on the rise globally and with it, the role interventional radiology (IR) has also expanded in managing this patient cohort. The role of damage control surgery (DCS) has been well established in the trauma management pathway, however it is only recently that Damage Control IR (DCIR) has become increasingly utilized in managing the extremis trauma and emergency patient.Visceral artery embolizations (both temporary and permanent), temporary balloon occlusions including Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in iliac arteries and aorta respectively are amongst the treatment options now available for the trauma (and non-traumatic bleeding) patient.We review the literature for the role of DCS and utilization of IR in trauma, outcomes and the paradigm shift towards minimally invasive techniques. The focus of this paper is to highlight the importance of multi-disciplinary working and having established pathways to ensure timely treatment of trauma patients as well as careful patient selection.We show that outcomes are best when both surgical and IR are involved in patient care from the outset and that DCIR should not be defined as Non-Operative Management (NOM) as it currently is categorized as.

Computed-Tomography-Guided Lung Biopsy: A Practice-Oriented Document on Techniques and Principles and a Review of the Literature.

Computed tomography (CT)-guided lung biopsy is one of the oldest and most widely known minimally invasive percutaneous procedures. Despite being conceptually simple, this procedure needs to be performed rapidly and can be subject to meaningful complications that need to be managed properly. Therefore, knowledge of principles and techniques is required by every general or interventional radiologist who performs the procedure. This review aims to contain all the information that the operator needs to know before performing the procedure. The paper starts with the description of indications, devices, and types of percutaneous CT-guided lung biopsies, along with their reported results in the literature. Then, pre-procedural evaluation and the practical aspects to be considered during procedure (i.e., patient positioning and breathing) are discussed. The subsequent section is dedicated to complications, with their incidence, risk factors, and the evidence-based measures necessary to both prevent or manage them; special attention is given to pneumothorax and hemorrhage. After conventional CT, this review describes other available CT modalities, including CT fluoroscopy and cone-beam CT. At the end, more advanced techniques, which are already used in clinical practice, like fusion imaging, are included.

Is it a complication or a consequence - a new perspective on adverse outcomes in Interventional Radiology.

The aim of the article is to introduce a new term in post-procedural events related to the procedure itself. All the Societies and Councils report these events as complications and they are divided in mild, moderate and severe or immediate and delayed.On the other hand the term error is known as the application of a wrong plan, or strategy to achieve a goal.For the first time, we are trying to introduce the term "consequence"; assuming that the procedure is the only available and the best fit to clinical indication, a consequence should be seen as an expected and unavoidable occurrence of an "adverse event" despite correct technical execution.

Prostate Artery Embolization (PAE) with Small Beads for the Treatment of Benign Prostatic Hyperplasia (BPH).

Benign Prostatic Hyperplasia (BPH) is the most frequent cause of Lower Urinary Tract Symptoms (LUTSs) in elderly populations. Minimally invasive treatments of BPH are safe and effective and are gaining popularity among both professionals and patients. Prostate Artery Embolization (PAE) has proven to be effective in Trans-Urethral Resection of the Prostate (TURP) in terms of prostate volume reduction and LUTS relief. PAE entails the selective catheterization of the prostatic artery and later embolization of distal vessels with beads of various calibers. Universal consensus regarding the ideal particle size is yet to be defined. We retrospectively evaluated 24 consecutive patients (median age: 75 years; range: 59-86 years) treated with PAE at our institution from October 2015 to November 2022. Particles of different sizes were employed; 12 patients were treated with 40-120 µm particles, 5 with 100 µm, 5 with 100-300 µm and 2 with 250 µm. Technical success, defined as selective prostate artery catheterization and controlled release of embolizing beads, was achieved in all patients. Removal vs. retention of the urinary catheter at the first post-procedural urological visit was the main clinical objective. No major peri-procedural complications were recorded, with 56% of patients successfully removing the urinary catheter.

Transcatheter Aortic Valve Implantation (TAVI) Planning with Dual-Layer Spectral CT Using Virtual Monoenergetic Image (VMI) Reconstructions and 20 mL of Contrast Media.

Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical implantation and its implementation is progressively increasing worldwide. We routinely perform pre-procedural aortic angiography CT to assess aortic dimensions and vascular anatomy. This study aims to evaluate the image quality of CTA for TAVI planning using dual-layer spectral CT, with virtual monoenergetic image reconstructions at 40 keV. Thirty-one patients underwent a CTA protocol with the injection of 20 mL of contrast media. Image quality was assessed by measuring the mean density in Hounsfield Units (HU), the signal-to-noise ratio, and the contrast-to-noise ratio in VMI reconstructions. Additionally, a blinded subjective analysis was conducted by two observers. The results showed significant enhancement at all sampled vascular levels with a gradual decrease in HU from proximal to distal regions. Favourable subjective ratings were given for all parameters, with greater variability in the evaluation of iliac axes. A significant negative correlation (p < 0.05) was observed between BMI and CA at all vascular levels, indicating reduced contrast enhancement with increasing BMI. Spectral CT, along with reducing iodine load, allows for obtaining high-quality images without a significant increase in noise. The reduction in iodine load can have positive implications in clinical practice, improving patient safety and resource efficiency.

Colonic involvement in inflammatory bowel diseases: spotlight on the role of magnetic resonance enterography.

The large bowel can be affected by inflammatory bowel diseases, namely ulcerative colitis and Crohn's disease, with the latter occurring either as a unique localization or in conjunction with simultaneous ileal involvement. The differential diagnosis among these conditions is challenging and relies on clinical symptoms, laboratory tests and endoscopy with biopsy. However, as these features can overlap, a conclusive diagnosis is not always achievable, and the underlying cause remains indeterminate. Currently, endoscopy is the reference standard for colonic assessment, although its invasiveness limits its use and repetition within a short timeframe. Magnetic Resonance Enterography is a non-invasive, radiation-free technique that has been extensively and effectively employed in the intestinal evaluation of patients with Crohn's disease in recent years. Although the main goal of this technique is generally focused on evaluating small bowel loops, it can also provide important information about the large bowel if an adequate fulfillment by the oral contrast medium is achieved. The purpose of this work is, therefore, to put emphasis on the potential role of Magnetic Resonance Enterography in assessing the large bowel. In fact, this imaging modality is capable of providing valuable information for comprehensive staging and follow-up of inflammatory bowel diseases within the large bowel, thus complementing the clinical picture and the endoscopic features in the context of a differential diagnosis.

Minimal Fat Content in Papillary Renal Cell Carcinoma Diagnosed with Dual-Layer Dual-Energy CT.

A 56-year-old man with a previous right nephrectomy for multiple papillary renal cell carcinomas (pRCC) underwent a follow-up CT scan. Using a dual-layer dual-energy CT (dlDECT), we demonstrated the presence of a small amount of fat in a 2.5 cm pRCC that mimicked the diagnosis of angiomyolipoma (AML). Histological examination demonstrated the absence of macroscopic intratumoral adipose tissue, showing a fair amount of enlarged foam macrophages loaded with intracytoplasmic lipids. The presence of fat density in an RCC is an extremely rare occurrence in the literature. To our knowledge, this is the first description using dlDECT of a minimal amount of fat tissue in a small RCC due to the presence of tumor-associated foam macrophages. Radiologists should be aware of this possibility when characterizing a renal mass with DECT. The option of RCCs must be considered, especially in the case of masses with an aggressive character or a positive history of RCC.

Computed Tomography Urography: State of the Art and Beyond.

Computed Tomography Urography (CTU) is a multiphase CT examination optimized for imaging kidneys, ureters, and bladder, complemented by post-contrast excretory phase imaging. Different protocols are available for contrast administration and image acquisition and timing, with different strengths and limits, mainly related to kidney enhancement, ureters distension and opacification, and radiation exposure. The availability of new reconstruction algorithms, such as iterative and deep-learning-based reconstruction has dramatically improved the image quality and reducing radiation exposure at the same time. Dual-Energy Computed Tomography also has an important role in this type of examination, with the possibility of renal stone characterization, the availability of synthetic unenhanced phases to reduce radiation dose, and the availability of iodine maps for a better interpretation of renal masses. We also describe the new artificial intelligence applications for CTU, focusing on radiomics to predict tumor grading and patients' outcome for a personalized therapeutic approach. In this narrative review, we provide a comprehensive overview of CTU from the traditional to the newest acquisition techniques and reconstruction algorithms, and the possibility of advanced imaging interpretation to provide an up-to-date guide for radiologists who want to better comprehend this technique.

Performance and Safety of a Reflux-Control Microcatheter Used to Perform DEB-TACE with LUMITM Beads in HCC Patients: Preliminary Experience.

PURPOSE: The present study aims to evaluate the effectiveness and safety of the anti-reflux microcatheter during DEB-TACE with DC Bead LUMITM (radiopaque beads) for the treatment of hepatocellular carcinoma (HCC). METHODS: We performed an observational longitudinal prospective monocentric study to analyze all patients with HCC who underwent to DEB-TACE with DC Bead LUMITM and anti-reflux microcatheter. Technical success, the presence of residual disease, and clinical success were evaluated. The performance of the anti-reflux microcatheter on the basis of the percentage of tumor covered and the non-target embolization (NTE) was also evaluated. RESULTS: Twenty patients underwent DEB-TACE with DC Bead LUMITM and an anti-reflux microcatheter. Technical success was achieved in all cases. Residual disease in the target tumor was observed in 11/20 (55%) of cases and no residual disease was found in 9/20 (45%) of cases. The clinical response at 1-month follow-up was of PD 4/20 (20%), SD 7/20 (35%), and CR 9/20 (45%). No major complications were recorded, and 10% of cases had minor complications. The distribution of beads on post-procedural CBCT, classified according to the percentage of target nodule coverage, was ≥50% in 70% (14/20) of cases and between 30-50% in 30% of cases (6/20). NTE was never registered.

Chest X-ray in Emergency Radiology: What Artificial Intelligence Applications Are Available?

Due to its widespread availability, low cost, feasibility at the patient's bedside and accessibility even in low-resource settings, chest X-ray is one of the most requested examinations in radiology departments. Whilst it provides essential information on thoracic pathology, it can be difficult to interpret and is prone to diagnostic errors, particularly in the emergency setting. The increasing availability of large chest X-ray datasets has allowed the development of reliable Artificial Intelligence (AI) tools to help radiologists in everyday clinical practice. AI integration into the diagnostic workflow would benefit patients, radiologists, and healthcare systems in terms of improved and standardized reporting accuracy, quicker diagnosis, more efficient management, and appropriateness of the therapy. This review article aims to provide an overview of the applications of AI for chest X-rays in the emergency setting, emphasizing the detection and evaluation of pneumothorax, pneumonia, heart failure, and pleural effusion.

Male breast: An unusual case of metastasis of squamous cell carcinoma of the skin.

Breast metastasis from extra-mammary neoplasm is a rare condition, accounting for approximately 1.2%-2% of all breast malignancies. Melanoma, lung cancer, gynecological, and hematological cancers can metastasis to the breast. Male breast metastasis is extremely rare and, no evidence of metastasis from cutaneous squamous cell carcinoma in a male breast have been reported to our knowledge. We describe a case of an 81-year-old man who came to our attention for a palpable solid mass in the upper-outer aspect of the left breast with the final histological diagnosis of breast metastasis from non-keratoblastic cutaneous squamous cell carcinoma.

Percutaneous Microwave Ablation of Hepatocellular Carcinoma with "Double Fusion" Technique: Technical Note and Single-Center Preliminary Experience.

Percutaneous image-guided thermal ablation is included in most society guidelines for treatment of hepatocellular carcinoma (HCC). The results of this treatment in terms of efficacy depend on the ability to precisely place the device into the target tumor. Ultrasound (US) is a commonly used imaging guidance modality for its real-time feedback. However, an accurate device deployment remains challenging in some clinical scenarios, including cases of tumors that are undetectable or not clearly visible by US. To overcome this problem, fusion imaging techniques have been developed, which combine images from different modalities. The most widely known technique combines pre-procedural contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) with real-time US scans. Cone beam CT (CBCT) is a technology that can provide intra-procedural cross-sectional images, which can be registered to images from other modalities, including preprocedural CT/MR scans. The aim of our study is to report the preliminary experience on percutaneous microwave ablation (MWA) of patients with HCC that were treated using the "double fusion" technique, which combines the use of US fusion imaging and CBCT fusion imaging. We describe the technical details, feasibility, safety and short-term efficacy of this technique in a small series of eight patients with 11 HCCs.

Percutaneous Ablation of T1 Renal Masses: Comparative Local Control and Complications after Radiofrequency and Cryoablation.

The efficacy and complication rates of percutaneous radiofrequency ablation (RFA) and cryoablation (CA) in the treatment of T1 renal masses in two Northern Italy hospitals were retrospectively investigated. Eighty-two patients with 80 T1a tumors and 10 T1b tumors treated with thermal ablation from 2015 through 2020 were included. A total of 43 tumors in 38 patients were treated with RFA (2.3 ± 0.9 cm), and 47 tumors in 44 patients were treated with CA (2.1 ± 0.8 cm). The mean follow-up observation period was 26 ± 19 months. The major complications and efficacy, as measured using the technical success and local tumor recurrence rates, were recorded. There were three (6.9%) technical failures with RFA and one (2.1%) with cryoablation (p = 0.30). Among the 40 tumors that were successfully treated with RFA, 1 tumor (2.5%) developed local tumor recurrence; 5/46 tumors that were treated with cryoablation (10.8%) developed local tumor recurrence (p = 0.17). T1b lesions (4.0 ± 0.7 cm) resulted in 1/6 technically unsuccessful cases with RFA and 0/4 with CA. No recurrent disease was detected in the T1b lesions. Major complications occurred after 2.3% (1/43) of RFAs and 0/47 of cryoablation procedures. RFA and cryoablation are both effective in the treatment of renal masses. Major complications with either procedure are uncommon.

Ablative Therapies for Breast Cancer: State of Art.

Breast cancer (BC) is the most frequently diagnosed malignancy among women. In the past two decades, new technologies and BC screening have led to the diagnosis of smaller and earlier-stage BC (ESBC). Therefore, percutaneous minimally invasive techniques (PMIT) were adopted to treat patients unfit for surgery, women who refuse it, or elderly patients with comorbidities that could make surgery a difficult and life-threatening treatment. The target of PMIT is small-size ESBC with the scope of obtaining similar efficacy as surgery. Minimally invasive treatments are convenient alternatives with promising effectiveness, lower morbidity, less cost, less scarring and pain, and more satisfying cosmetic results. Ablative techniques used in BC are cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused ultrasound (US), and laser ablation. The aim of our study is to discuss the current status of percutaneous management of BC, evaluate the clinical outcomes of PMIT in BC, and analyze future perspectives regarding ablation therapy in BC.

Virtual Non-Contrast Spectral CT in Renal Masses: Is It Time to Discard Conventional Unenhanced Phase?

Dual-layer Dual-Energy CT (dl-DECT) allows one to create virtual non-contrast (VNC) reconstructions from contrast-enhanced CT scans, with a consequent decrease of the radiation dose. This study aims to assess the reliability of VNC for the diagnostic evaluation of renal masses in comparison with true non-contrast (TNC) images. The study cohort included 100 renal masses in 40 patients who underwent dl-DECT between June and December 2021. Attenuation values and standard deviations were assessed through the drawing of regions of interest on TNC and VNC images reconstructed from corticomedullary and nephrographic phases. A Wilcoxon signed-rank test was performed in order to assess equivalence of data and Spearman's Rho correlation coefficient to evaluate correlations between each parameter. The diagnostic accuracy of VNC was estimated through the performance of receiver operating characteristic (ROC) curve analysis. Differences between attenuation values were, respectively, 74%, 18%, 5% and 3% (TNC-VNCcort), and 74%, 15%, 9% and 2% (TNC-VNCneph). The Wilcoxon signed-rank test demonstrated the equivalence of attenuation values between the TNC and VNC images. The diagnostic performance of VNC images in the depiction of kidney simple cysts remains high compared to TNC (VNCcort-AUC: 0.896; VNCneph-AUC: 0.901, TNC-AUC: 0.903). In conclusion, quantitative analysis of attenuation values showed a strong agreement between VNC and TNC images in the evaluation of renal masses.