Early Embolization After Carotid Artery Stenting with Mesh-Covered Stent: Role of Diffusion-Weighted Magnetic Resonance Imaging as Pre-procedural Predictor and Discriminant Between Intra- and Post-procedural Events.

OBJECTIVES: To evaluate the incidence and the time of onset of early micro-embolism after CAS (carotid artery stenting) with two different mesh-covered stents and to assess the role of DW-MRI (Diffusion-weighted magnetic resonance imaging) in their prediction. METHODS: Single-institution prospective study including 50 patients (33 male, median age 74 years) who underwent CAS with Roadsaver® or CGuard™. All patients with primary stenosis (37/50, 74%) had carotid plaque DW-MRI pre-procedure, with both qualitative evaluation of the hyperintensity and ADC (apparent diffusion coefficient) measurement of the plaque. All patients had brain DW-MRI pre-procedure, at 1 h, 24 h and 30 days post-procedure to evaluate the appearance of hyperintense lesions over time. Imaging analysis was performed in a double-blinded fashion by two radiologists. RESULTS: There were no statistically significant differences between the two stents both in the incidence at 1 h (P = 0.23) and 24 h (P = 0.36) and in the volume of new DWI hyperintense brain lesions at 24 h (P = 0.27). Thirty-four new asymptomatic lesions in 19 patients (38%) were reported: 4 (11.8%) at 1 h, 30 (88.2%) at 24 h. The 30-day DWI-MR showed complete resolution of all lesions and no evidence of new lesion. The incidence of new lesions at 24 h resulted significantly higher in patients with DWI hyperintense carotid plaques (12/16, 75% vs. 0/21, 0%, P < 0.0001). This result was paralleled by the difference in ADC value (0.83 ± 0.21 vs. 1.42 ± 0.52). CONCLUSION: The majority of early asymptomatic brain lesion occurred during the first 24 h after CAS. Pre-procedure high DWI signal of the plaque was associated with an increased incidence of post-procedure microembolizations.

Can DW-MRI, with its ADC values, be a reliable predictor of biopsy outcome in patients with suspected prostate cancer?

PURPOSE: To relate the multiparametric magnetic resonance imaging (mp-MRI) of patients with suspect peripheral prostate cancer (PCa) to the results of the subsequent biopsy: in particular to explore whether DWI and ADC can predict the biopsy outcome and to investigate the relation between ADC and Gleason score (GS). MATERIALS AND METHODS: 175 consecutive patients who underwent 1.5 T mp-MRI followed by prostate biopsy were retrospectively analyzed by two independent radiologists. ADC values were measured in the peripheral suspect lesion areas (ADCSL) and in the contralateral zones (ADCNSL) obtaining ADCnorm = ADCSL/ADCNSL. Results on T2W images, DWI, ADC values, and perfusion studies were matched to their corresponding biopsy. RESULTS: Negative DWI and T2W had 100% negative predictive value (NPV). When DWI was positive, ADCSL > 0.90 × 10 > 0.90 × 10(-3) mm(2)/s (ADCnorm > 0.60) identified by the ROC curve (AUC = 0.80) corresponded to NPV = 85%. In positive biopsies, ADCSL and ADCnorm decreased significantly from GS = 6 to GS ≥ 8 with Spearman coefficient ρ = -0.40 and ROC curve AUC = 0.72. CONCLUSION: mp-MRI allows a reliable prediction of a negative biopsy through the values of DWI, T2W, and ADC. In positive biopsies, there is a moderate correlation between ADC and the various GS levels.

Practice parameters for early colon cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines.

Early colon cancer (ECC) has been defined as a carcinoma with invasion limited to the submucosa regardless of lymph node status and according to the Royal College of Pathologists as TNM stage T1 NX M0. As the potential risk of lymph node metastasis ranges from 6 to 17% and the preoperative assessment of lymph node metastasis is not reliable, the management of ECC is still controversial, varying from endoscopic to radical resection. A meeting on recent advances on the management of colorectal polyps endorsed by the Italian Society of Colorectal Surgery (SICCR) took place in April 2014, in Genoa (Italy). Based on this material the SICCR decided to issue guidelines updating the evidence and to write a position statement paper in order to define the diagnostic and therapeutic strategy for ECC treatment in context of the Italian healthcare system.

Practice parameters for early rectal cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines.

The introduction of new technologies for diagnosis and screening programs led to an increasing rate of early detection of colorectal cancer. This, associated with the evolution of endoscopic techniques of local excision, led to the assessment of new strategies to reduce morbidity related to treatment, especially for early rectal cancer (ERC). Nevertheless, the definition of ERC and its staging and treatment algorithm are still under debate. The Italian Society of Colorectal Surgery developed practice guidelines to provide recommendations on the diagnosis, staging and treatment of ERC. A systematic review on the topic was performed by a multidisciplinary group of experts selected based on their clinical and scientific expertise in endoscopy, endoscopic ultrasound, magnetic resonance and surgery, with the aid of an external international audit.

Autoimmune lymphoproliferative syndrome and non-Hodgkin lymphoma: what 18F-fluorodeoxyglucose positron emission tomography/computed tomography can do in the management of these patients? Suggestions from a case report.

A young patient with undefined autoimmune lymphoproliferative syndrome (ALPS-U) and low back pain underwent a CT and MRI study that showed enhancing vertebral lesions, some pulmonary nodules and diffuse latero-cervical lymphadenopathy. A (18)F-FDG-PET/CT scan showed many areas of intense (18)F-FDG uptake in multiple vertebrae, in some ribs, in the sacrum, in the liver, in both lungs, in multiple lymph nodes spread in the cervical, thoracic and abdominal chains. A bone marrow biopsy showed a "lymphomatoid granulomatosis", a rare variant of B-cell non-Hodgkin lymphoma (NHL). After the treatment, the (18)F-FDG-PET/CT scan showed a complete metabolic response.

[Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging]. / Indicazioni cliniche per l'utilizzo della cardio RM. A cura del Gruppo di lavoro della Sezione di Cardio-Radiologia della SIRM.

Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.

Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM).

Cardiac computed tomography (CCT) has grown as a useful means in different clinical contexts. Technological development has progressively extended the indications for CCT while reducing the required radiation dose. Even today there is little documentation from the main international scientific societies describing the proper use and clinical indications of CCT; in particular, there are no complete guidelines. This document reflects the position of the Working Group of the Cardiac Radiology Section of the Italian Society of Radiology concerning the indications for CCT.

Radiation dose evaluations during radiological contrast studies in patients with morbid obesity.

PURPOSE: The purpose of this study was to evaluate the radiation dose to patients during radiological contrast studies performed after vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGBP) surgery in patients with morbid obesity. MATERIALS AND METHODS: Dose evaluations were performed on a sample of 39 patients (32 women and 7 men) with a mean weight of 117 kg (range 68-175 kg) and a mean body mass index (BMI) of 43.7 (range 22.2-54.9). Between the second and seventh postoperative day, patients underwent radiological follow-up after oral administration of approximately 70 ml of water-soluble iodinated contrast material (Gastrografin) and images acquired in anteroposterior, right and left oblique projections with the patient upright and then supine. Exposure conditions, dose-area product (DAP) and entrance skin dose (ESD) were recorded for each procedure. On the basis of these data, the effective dose (ED) was calculated using simulation software based on the Monte Carlo method for determining the absorbed dose to organs. To assess the optimal exposure conditions and the dose contributions of fluoroscopy and radiography, the effective dose rates were also evaluated using Plexiglas phantoms of different thickness to simulate different patient sizes. RESULTS: The phantom measurements showed a fourfold dose increase when passing from normal-sized patients to obese patients. Mean DAP value obtained from in-vivo measurements was 70 Gy cm(2) (range 17-147 Gy cm(2)), and mean effective dose was 21 mSv (range 5-45 mSv). CONCLUSIONS: When performing radiological contrast studies in patients with morbid obesity, every possible precaution should be taken to minimise patient dose. Special care should be taken to evaluate justification of the radiological procedure.

Interventional procedures for biliary drainage with bilioplasty in pediatric patients: dosimetric aspects.

PURPOSE: This study was undertaken to evaluate patient dose in paediatric liver transplant recipients treated by percutaneous biliary drainage and bilioplasty procedures. MATERIALS AND METHODS: Effective dose rates and entrance skin-dose (ESD) rates per minute of fluoroscopy were measured by using a plexiglas phantom (thickness 10 cm) simulating the patient and by varying the exposure parameters (type of pulsed fluoroscopy, image intensifier diameter, presence of diaphragms) to identify the technique delivering the lowest patient dose. In vivo measurements were performed during three interventional procedures. RESULTS: The effective dose rate proved to be lowest for a particular type of pulsed fluoroscopy, with maximum magnification and with field-limiting diaphragms. The in vivo measurements showed a maximum ESD value of around 50 MGY (the threshold for transient erythema is 2,000 MGY, ICRP 60). The effective dose values were in the range of 0.9-1.5 MSV. CONCLUSIONS: We established exposure parameters providing the desired image quality with the lowest dose for the equipment used and for a specific type of interventional procedure. The measured ESD values allow us to exclude the risk of deterministic effects on the skin. The effective dose values and considerations regarding the likelihood of radiation-induced cancer led to the conclusion that the radiological risk for the patient is largely justified by the benefits of these kinds of procedure.