Magnetic Resonance Imaging after Nasopharyngeal Endoscopic Resection and Skull Base Reconstruction.

Background: Postoperative imaging after nasopharyngeal endoscopic resection (NER) and skull base reconstruction is quite challenging due to the complexity of the post-surgical and regional anatomy. Methods: In this retrospective observational study, we included patients treated with NER from 2009 to 2019 and submitted to Magnetic Resonance Imaging (MRI) 6 and 12 months after surgery. A radiologist with 15 years of experience analyzed all MRI scans. Results: A total of 50 patients were considered in this study, 18 of whom were excluded due to imaging unavailability, and 16 of whom were not considered due to major complications and/or persistent disease. Sixteen patients were evaluated to identify the expected findings. Inflammatory changes were observed in 16/64 subsites, and regression of these changes was observed in 8/64 at 1 year. Fibrosis was observed in 5/64 subsites and was unmodified at 1 year. The nasoseptal flap showed homogeneous enhancement at 6 months (100%) and at 1 year. The temporo-parietal fascia flap (TPFF) showed a decrease in the T2- signal intensity of the mucosal layer in 57% of the patients at 1 year and a decrease in enhancement in 43%. Conclusions: Identifying the expected findings after NER and skull base reconstruction has a pivotal role in the identification of complications and recurrence.

CT and MR anatomy of the larynx and hypopharynx.

Imaging of the larynx and hypopharynx is frequently requested to assess the extent of neoplasms beyond the field of view of endoscopic evaluation. The combination of optical and cross-sectional imaging allows tumors to be classified according to AJCC/UICC guidelines. A thorough understanding of laryngeal and hypopharyngeal anatomy is crucial to guide the radiological eye along the possible pathways of the spread of diseases and to guide differential diagnoses. Computed tomography (CT) has been the first cross-sectional imaging technique used to evaluate the larynx and hypopharynx; its spatial resolution combined with volumetric capability and the use of injectable contrast medium made CT the working horse in the assessment of neoplastic and inflammatory diseases. In the last two decades, magnetic resonance (MR) supported CT in the most challenging cases, when the optimal contrast resolution due to the multisequence portfolio is needed to assess the neoplastic involvement of laryngeal cartilages, paraglottic space(s), and extra laryngeal spread. The aim of this paper is to give a comprehensive radiological overview of larynx and hypopharynx complex anatomy, combining in vivo images, anatomical sections, and images of ex vivo specimens.

Unresectable stage III non-small cell lung cancer: could durvalumab be safe and effective in real-life clinical scenarios? Results of a single-center experience.

Introduction: The standard of care for patients with unresectable stage III non-small cell lung cancer (NSCLC) is chemoradiotherapy (CRT) followed by consolidation durvalumab as shown in the PACIFIC trial. The purpose of this study is to evaluate clinical outcomes and toxicities regarding the use of durvalumab in a real clinical scenario. Methods: A single-center retrospective study was conducted on patients with a diagnosis of unresectable stage III NSCLC who underwent radical CRT followed or not by durvalumab. Tumor response after CRT, pattern of relapse, overall survival (OS) and progression-free survival (PFS), and toxicity profile were investigated. Results: Eighty-five patients met the inclusion criteria. The median age was 67 years (range 45-82 years). Fifty-two patients (61.2%) started sequential therapy with durvalumab. The main reason for excluding patients from the durvalumab treatment was the expression of PD-L1 < 1%. Only two patients presented a grade 4 or 5 pneumonitis. A median follow-up (FU) of 20 months has been reached. Forty-five patients (52.9%) had disease progression, and 21 (24.7%) had a distant progression. The addition of maintenance immunotherapy confirmed a clinical benefit in terms of OS and PFS. Two-year OS and PFS were respectively 69.4% and 54.4% in the durvalumab group and 47.9% and 24.2% in the no-durvalumab group (p = 0.015, p = 0.007). Conclusion: In this real-world study, patients treated with CRT plus durvalumab showed clinical outcomes and toxicities similar to the PACIFIC results. Maintenance immunotherapy after CRT has been shown to be safe and has increased the survival of patients in clinical practice.

Software-based quantitative CT analysis to predict the growth trend of persistent nonsolid pulmonary nodules: a retrospective study.

PURPOSE: Persistent nonsolid nodules (NSNs) usually exhibit an indolent course and may remain stable for several years; however, some NSNs grow quickly and require surgical excision. Therefore, identifying quantitative features capable of early discrimination between growing and nongrowing NSNs is becoming a crucial aspect of radiological analysis. The main purpose of this study was to evaluate the performance of an open-source software (ImageJ) to predict the future growth of NSNs detected in a Caucasian (Italian) population. MATERIAL AND METHODS: We retrospectively selected 60 NSNs with an axial diameter of 6-30 mm scanned with the same acquisition-reconstruction parameters and the same computed tomography (CT) scanner. Software-based analysis was performed on thin-section CT images using ImageJ. For each NSNs, several quantitative features were extracted from the baseline CT images. The relationships of NSN growth with quantitative CT features and other categorical variables were analyzed using univariate and multivariable logistic regression analyses. RESULTS: In multivariable analysis, only the skewness and linear mass density (LMD) were significantly associated with NSN growth, and the skewness was the strongest predictor of growth. In receiver operating characteristic curve analyses, the optimal cutoff values of skewness and LMD were 0.90 and 19.16 mg/mm, respectively. The two predictive models that included the skewness, with or without LMD, exhibited an excellent power for predicting NSN growth. CONCLUSION: According to our results, NSNs with a skewness value > 0.90, specifically those with a LMD > 19.16 mg/mm, should require closer follow-up due to their higher growth potential, and higher risk of becoming an active cancer.

Home-based pulmonary rehabilitation in patients undergoing (chemo)radiation therapy for unresectable lung cancer: a prospective explorative study.

AIMS: The prevention of pulmonary toxicity is an important goal for patient candidate to radiation therapy for lung cancer. There is a lack of evidence on the role of exercise training for patients with unresectable stage III lung cancer candidated to radical treatment. The aim of this study was to evaluate the feasibility of a home-based pulmonary rehabilitation (PR) program and to identify reliable tools in terms of respiratory function, exercise capacity and quality of life. METHODS: Patients' recruitment lasted from April 2020 till February 2022. The PR program was proposed concomitantly to radiation therapy to the first 20 patients (interventional group, IG), and the other 20 patients were identified as an observational group (OG). All patients were assessed at baseline (T0) and after 8 weeks (T2) with 6 minute walking test (6MWT), modified Borg Scale (mBORG), SF-36 questionnaire (SF-36) and pulmonary function test (PFT); after 4 weeks (T1), only SF-36 was administered. RESULTS: A decrease of 13.8 m in the walked-distance was registered in the OG between T0 and T2 (p = 0.083). Instead, an increase of 56.6 m in the distance walked was recorded in the IG between T0 and T2 (p ≤ 0.001). In the OG, the mBORG scores showed a negative trend. On the contrary, in the IG, these scores showed a slight improvement. In the OG, all the items of SF-36 scores decreased between T0 and T1. In the IG, an increased trend from T0 to T2 was observed for all the items of SF-36. No clinically significant variations were detected from baseline to T2 in both groups regarding PFT. CONCLUSION: The 6MWT, mBORG and SF-36 resulted as useful tools to assess the role of a PR program. A significant gain in functional exercise capacity and a prevention of the physiological impairment of QoL during radio(chemo)therapy was registered.

Every cloud has a silver lining: COVID-19 chest-CT screening prevents unnecessary cardiac surgery.

BACKGROUND: Unenhanced chest CT can identify incidental findings (IFs) leading to management strategy change. We report our institutional experience with routine chest-CT as preoperative screening tool during the COVID-19 pandemic, focusing on the impact of IFs. METHODS: All patients scheduled for cardiac surgery from May 1st to December 31st 2020, underwent preoperative unenhanced chest-CT according to COVID-19 pandemic institutional protocol. We have analyzed IFs incidence, reported consequent operative changes, and identified IFs clinical determinants. RESULTS: Out of 447, 278 patients were included. IFs rate was 7.2% (20/278): a solid mass (11/20, 55%), lymphoproliferative disease (1/20, 5%), SARS-CoV-2 pneumonia (2/20, 10%), pulmonary artery chronic thromboembolism (1/20, 5%), anomalous vessel anatomy (2/20, 10%), voluminous hiatal hernia (1/20, 5%), mitral annulus calcification (1/20, 5%), and porcelain aorta (1/20, 5%) were reported. Based on IFs, 4 patients (20%-4/278, 1.4%) were not operated, 8 (40%-8/278, 2.9%) underwent a procedure different from the one originally planned one, and 8 (40%-8/278, 2.9%) needed additional preoperative investigations before undergoing the planned surgery. At univariate regression, coronary artery disease, atrial fibrillation, and history of cancer were significantly more often present in patients presenting with significant IFs. History of malignancy was identified as the only independent determinant of significant IFs at chest-CT (OR=4.27 IQR: [1.14-14.58], P=0.0227). CONCLUSIONS: Unenhanced chest-CT as a preoperative screening tool in cardiac surgery led to incidental detection of significant clinical findings, which justified even procedures cancellation. Malignancy history is a determinant for CT incidental findings and could support a tailored screening approach for high-risk patients.

Anterior and Central Skull Base Tumors: Key Points for the Radiologist to Analyze Prior to Endoscopic Approaches.

Initially developed as a minimally invasive technique to approach inflammatory conditions, transnasal endoscopic surgery has progressively expanded its anatomic targets and clinical indications. Consequently, numerous surgical approaches to the anterior and central skull base were developed, referred to as extended endonasal approaches (EEA). The intrinsic advantage of EEA is the exploitation of a natural corridor provided by sinonasal airspaces, with no need for skin incision and osteotomy and limited soft tissue damage. In this context, imaging plays essential role, demonstrating the relevant anatomic relationships of the lesion, the proper surgical corridor, the anatomic variants that may increase the surgical risk.

Structured Reporting of Lung Cancer Staging: A Consensus Proposal.

BACKGROUND: Structured reporting (SR) in radiology is becoming necessary and has recently been recognized by major scientific societies. This study aimed to build CT-based structured reports for lung cancer during the staging phase, in order to improve communication between radiologists, members of the multidisciplinary team and patients. MATERIALS AND METHODS: A panel of expert radiologists, members of the Italian Society of Medical and Interventional Radiology, was established. A modified Delphi exercise was used to build the structural report and to assess the level of agreement for all the report sections. The Cronbach's alpha (Cα) correlation coefficient was used to assess internal consistency for each section and to perform a quality analysis according to the average inter-item correlation. RESULTS: The final SR version was built by including 16 items in the "Patient Clinical Data" section, 4 items in the "Clinical Evaluation" section, 8 items in the "Exam Technique" section, 22 items in the "Report" section, and 5 items in the "Conclusion" section. Overall, 55 items were included in the final version of the SR. The overall mean of the scores of the experts and the sum of scores for the structured report were 4.5 (range 1-5) and 631 (mean value 67.54, STD 7.53), respectively, in the first round. The items of the structured report with higher accordance in the first round were primary lesion features, lymph nodes, metastasis and conclusions. The overall mean of the scores of the experts and the sum of scores for staging in the structured report were 4.7 (range 4-5) and 807 (mean value 70.11, STD 4.81), respectively, in the second round. The Cronbach's alpha (Cα) correlation coefficient was 0.89 in the first round and 0.92 in the second round for staging in the structured report. CONCLUSIONS: The wide implementation of SR is critical for providing referring physicians and patients with the best quality of service, and for providing researchers with the best quality of data in the context of the big data exploitation of the available clinical data. Implementation is complex, requiring mature technology to successfully address pending user-friendliness, organizational and interoperability challenges.

Posttreatment Imaging Surveillance.

Posttreatment imaging surveillance in patients treated for anterior skull base tumors is a multifaceted issue which - as a first step - requires tailoring of the selection of imaging technique and acquisition protocol to the clinical scenario. As a general rule, acute symptoms suggesting the onset of a complication of treatment require prompt diagnosis through an easily accessible technique, such as CT; on the other hand, monitoring recurrences in asymptomatic patients is best achieved with MRI, exploiting the inherently higher contrast resolution. The interpretation of follow-up imaging studies is challenging. First of all, it is essential to be aware of specific characteristics of the natural history that may differ significantly between histologies, influencing the pattern and timing of recurrences. Additionally, resection of the lesion and reconstruction of the defect (as well as radiation treatment) produce complex anatomical changes, which may mislead inexperienced radiologists; this concept emphasizes the centrality of collecting accurate information on treatment modalities and procedures applied before scanning in each patient. This enables the pattern of expected posttreatment changes to be anticipated and, consequently, recurrences or complications to be more easily identified.

The Role of Morphologic and Functional Imaging in Pretreatment Assessment.

Anterior skull base (ASB) tumors can be classified into three groups according to their site of origin: (1) sinonasal neoplasms involving or extending through the anterior cranial base; (2) neoplasms which arise from the bony framework of the base itself; (3) neoplasms originating from adjacent intracranial structures. With few exceptions, most of these tumors have a non-specific appearance on CT and MRI, which limits the role of imaging in terms of characterization. However, treatment planning (transnasal endoscopic surgery in particular) mostly depends upon the tumor map, exploiting the potential of modern cross-sectional imaging. As a result, the radiologist who has to evaluate a neoplasm involving the ASB needs to be fully aware of all the technical solutions available and the specific strengths/weaknesses of the different imaging techniques. Knowledge of radiological anatomy (and its variants) is also essential, which includes the ability to translate the CT appearance of structures into the equivalent MR signal (and vice versa). These main prerequisites have to be combined with up-to-date knowledge of treatment options and surgical procedures in order to be able to create a reporting checklist covering all the aspects that are essential for clinical decision making.

What's New on Quantitative CT Analysis as a Tool to Predict Growth in Persistent Pulmonary Subsolid Nodules? A Literature Review.

Pulmonary subsolid nodules (SSNs) are observed not infrequently on thin-section chest computed tomography (CT) images. SSNs persisting after a follow-up period of three to six months have a high likelihood of being pre-malignant or malignant lesions. Malignant SSNs usually represent the histologic spectrum of pulmonary adenocarcinomas, and pulmonary adenocarcinomas presenting as SSNs exhibit quite heterogeneous behavior. In fact, while most lesions show an indolent course and may grow very slowly or remain stable for many years, others may exhibit significant growth in a relatively short time. Therefore, it is not yet clear which persistent SSNs should be surgically removed and for how many years stable SSNs should be monitored. In order to solve these two open issues, the use of quantitative analysis has been proposed to define the "tailored" management of persistent SSNs. The main purpose of this review was to summarize recent results about quantitative CT analysis as a diagnostic tool for predicting the behavior of persistent SSNs. Thus, a literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science databases to find original articles published from January 2014 to October 2019. The results of the selected studies are presented and compared in a narrative way.

Pulmonary metastases from malignant epithelioid schwannoma of the arm presenting as fast-growing subsolid nodules: Report of an unusual case.

Subsolid pulmonary nodules (SSNs) may be the manifestation of benign and malignant conditions. Malignant SSNs usually correspond to the preinvasive or invasive lepidic growth of pulmonary adenocarcinomas. More rarely, malignant SSNs may be the manifestation of primitive pulmonary lymphomas or metastases from extrapulmonary malignancies. In the case of metastases from extrapulmonary malignancies, the SSNs exhibit more aggressive behavior with rapid growth in a short period of time. The present article describes the first case of pulmonary metastases presenting as fast-growing SSNs in a patient with malignant epithelioid schwannoma of the arm.

Two synchronous lung metastases from malignant melanoma: the same patient but different morphological patterns.

Malignant melanoma is an aggressive cancer with a high metastatic potential. Among the multiple sites of metastatic disease, the lung is one of the most frequently involved sites. Typically, pulmonary metastases from malignant melanoma occur as solid nodules. Rarely, pulmonary involvement in metastatic melanoma occurs as subsolid nodules. The present article describes an unusual case of a patient with malignant melanoma that developed two synchronous pulmonary metastases with two different densities on CT images (one solid and the other subsolid) and different morphological patterns on histologic images. The radiologic-pathologic correlation of these two patterns of presentation was also reported.

Solid Indeterminate Pulmonary Nodules of Less Than 300 mm3: Application of Different Volume Doubling Time Cut-offs in Clinical Practice.

In the British Thoracic Society guidelines for incidental pulmonary nodules, volumetric analysis has become the recommended method for growth assessment in solid indeterminate pulmonary nodules (SIPNs) <300 mm3. In these guidelines, two different volume doubling time (VDT) cut-offs, 400 and 600 days, were proposed to differentiate benign from malignant nodules. The present study aims to evaluate the performance of these VDT cut-offs in a group of SIPNs <300 mm3 which were incidentally detected in a routine clinical setting. During a 7-year period, we retrospectively selected 60 patients with a single SIPN <300 mm3. For each SIPN, the volume and VDT were calculated using semiautomatic software throughout the follow-up period, and the performance of the 400- and 600-day VDT cut-offs was compared. In the selected sample, there were 38 benign and 22 malignant nodules. In this group of nodules, the sensitivity, negative predictive value and accuracy of the 600-day VDT cut-off were higher than those of the 400-day VDT cut-off. Therefore, in the management of SIPNs <300 mm3 which were incidentally detected in a clinical setting, the 600-day VDT cut-off was better at differentiating benign from malignant nodules than the 400-day VDT cut-off, by reducing the number of false negatives.

Solid Indeterminate Pulmonary Nodules Less Than or Equal to 250 mm3: Application of the Updated Fleischner Society Guidelines in Clinical Practice.

BACKGROUND: The latest version of the Fleischner Society guidelines for management of incidental pulmonary nodules was published in 2017. The main purpose of these guidelines is to reduce the number of unnecessary computed tomography (CT) examinations during the follow-up of small indeterminate nodules. OBJECTIVE: The present study aimed to evaluate the performance of these guidelines for management of solid indeterminate pulmonary nodules (SIPNs) ≤ 250 mm3. MATERIALS AND METHODS: During a 7-year period, we retrospectively reviewed the chest CT scans of 672 consecutive patients with SIPNs. The study sample was selected according to the following inclusion criteria: solitary SIPN; diameter ≥ 3 mm; volume ≤ 250 mm3; two or more CT scans performed with the same scanner and same acquisition/reconstruction protocol; thin-section 1-mm images in DICOM format; histologic diagnosis or follow-up ≥ 2 years; and no oncological history. Applying these criteria, a total of 27 patients with single SIPNs ≤ 250 mm3 were enrolled. For each SIPN, the volume and doubling time were calculated using semiautomatic software throughout the follow-up period. For each SIPN, we applied the Fleischner Society guidelines, and the recommended management was compared to what was actually done. RESULTS: A significant volumetric increase was detected in 5/27 (18.5%) SIPNs; all growing nodules were observed in high-risk patients. In these SIPNs, a histologic diagnosis of malignancy was obtained. Applying the Fleischner Society recommendations, all five malignant nodules would have been identified. None of the SIPNs < 100 mm3 in low-risk patients showed significant growth during the follow-up period. The application of the new guidelines would have led to a significant reduction in follow-up CT examinations (Hodges-Lehmann median difference, -2 CT scans; p = 0.0001). CONCLUSION: The application of the updated Fleischner Society guidelines has been shown to be effective in the management of SIPNs ≤ 250 mm3 with a significant reduction in radiation dose.

CT texture analysis as predictive factor in metastatic lung adenocarcinoma treated with tyrosine kinase inhibitors (TKIs).

PURPOSE: To assess the predictive and prognostic value of pre-treatment CT texture features in lung adenocarcinoma treated with tyrosine kinase inhibitors (TKI). MATERIALS AND METHODS: Texture analysis was performed using commercially available software (TexRAD Ltd, Cambridge, UK) on pre-treatment contrast-enhanced CT studies from 50 patients with metastatic lung adenocarcinoma treated by TKI. Texture features were quantified on a 5-mm-thick central slice of the primary tumor and were correlated with progression-free and overall survival (PFS and OS) using an internally cross-validated machine learning approach then validated on a bootstrapped sample. RESULTS: Median PFS and OS were 10.5 and 20.7 months, respectively. A noninvasive signature based on five texture parameters predicted 6-month progression with Area Under the Curve (AUC) of 0.8 (95% CI) and 1-year progression with AUC of 0.76. A high-risk group had hazard ratios for progression of 4.63 and 5.78 when divided by median and best cut-off points, respectively. Texture signature did not correlate with OS. Available clinical variables did not correlate with PFS or with OS. CONCLUSION: Texture features seem to be associated with PFS in lung adenocarcinoma treated with TKI.

Pulmonary hamartoma mimicking a mediastinal cyst-like lesion in a heavy smoker.

Pulmonary hamartoma (PH) is the most common benign tumor of the lung, typically presenting as a peripheral solitary nodule with round shape and smooth margins. The main computed tomography (CT) features that allow a confident diagnosis of PH are intranodular fat and popcorn-like calcifications. However, the presence of these features within PHs is variable. Thus, a reliable diagnosis of PH cannot be formulated in approximately 30% of cases. Furthermore, PHs may occasionally show atypical CT features. The present article reports the case of a centrally located PH with an extremely rare and previously unreported CT presentation consisting of fluid attenuation, rim enhancement and thick enhancing septa that mimicked a mediastinal cyst-like lesion.

Odontogenic keratocyst: imaging features of a benign lesion with an aggressive behaviour.

The latest (4th) edition of the World Health Organization (WHO) Classification of Head and Neck Tumours, published in January 2017, has reclassified keratocystic odontogenic tumour as odontogenic keratocyst. Therefore, odontogenic keratocysts (OKCs) are now considered benign cysts of odontogenic origin that account for about 10% of all odontogenic cysts. OKCs arise from the dental lamina and are characterised by a cystic space containing desquamated keratin with a uniform lining of parakeratinised squamous epithelium. The reported age distribution of OKCs is considerably wide, with a peak of incidence in the third decade of life and a slight male predominance. OKCs originate in tooth-bearing regions and the mandible is more often affected than the maxilla. In the mandible, the most common location is the posterior sextant, the angle or the ramus. Conversely, the anterior sextant and the third molar region are the most common sites of origin in the maxilla. OKCs are characterised by an aggressive behaviour with a relatively high recurrence rate, particularly when OKCs are associated with syndromes. Multiple OKCs are typically associated with the nevoid basal cell carcinoma syndrome (NBCCS), an autosomal dominant multisystemic disease. Radiological imaging, mainly computed tomography (CT) and, in selected cases, magnetic resonance imaging (MRI), plays an important role in the diagnosis and management of OKCs. Therefore, the main purpose of this pictorial review is to present the imaging appearance of OKCs underlining the specific findings of different imaging modalities and to provide key radiologic features helping the differential diagnoses from other cystic and neoplastic lesions of odontogenic origin. KEY POINTS: • Panoramic radiography is helpful in the preliminary assessment of OKCs. • CT is considered the tool of choice in the evaluation of OKCs. • MRI with DWI or DKI can help differentiate OKCs from other odontogenic lesions. • Ameloblastoma, dentigerous and radicular cysts should be considered in the differential diagnosis. • The presence of multiple OKCs is one of the major criteria for the diagnosis of NBCCS.