High-Resolution Ultrasound of Odontogenic Cutaneous Sinus Tract: An International Multicentric Experience and a Review of the Literature.

OBJECTIVES: To investigate the role of high-resolution ultrasound (HR-US) in the initial and differential diagnosis of the Odontogenic Cutaneous Sinus Tract (OCST) in a multicentric setting. METHODS: Skin HR-US examinations of OCSTs performed between January 2019 and June 2023 at different Institutions were retrospectively reviewed. Epidemiological and clinical data (age, gender, location of the skin lesion, causative tooth, and the clinical suspicion) as well as HR-US imaging findings (morphology and length of the sinus tract, Doppler signal, and cortical bone interruption of maxilla or mandible) were collected. US examinations were performed by expert radiologists using a high-performance US scanner, employing a high-frequency linear probe (15 MHz or higher frequencies). In only one patient the HR-US exam was integrated with strain elastography (SE). RESULTS: Sixteen patients were enrolled with a median age of 37.6 years (range 16-70 years). The most frequent clinical suspicion was epidermal cyst, while OCST was suspected in only two cases. In all cases, HR-US depicted the sinus tract as a nodular, triangular or "champignon-shaped" lesion in the subcutaneous layer, which continued with a slightly tortuous band structure, up to the focally interrupted cortical bone plate. Furthermore, color Doppler evaluation showed color signals around and/or within the lesion, expression of inflammation. On SE, the sinus tract showed a hard pattern, due to fibrous and granulomatous tissue. CONCLUSIONS: HR-US, thanks to its high spatial resolution, allows the evaluation of OCST, and play a crucial diagnostic role, mainly when the clinical suspicious is different.

Isolate scapulothoracic dislocation: Radiological findings and management.

Scapulothoracic dislocation (STD) is a rare condition consisting in the loss of anatomical relations of the scapula with the posterior chest wall. This pathological condition commonly occurs after a scapular region trauma or an upper arm distractive injury. Here-in, we present a case of STD occurring in a young male patient, and we discuss the mechanism of injury, the radiological imaging features, and how it can guide and help the orthopedist in the management.

Breast ultrasound: An opportunity to detect unsuspected pleural and pulmonary abnormalities.

PURPOSE: While scanning women for breast US, is possible to observe changes in the appearance of the pleural line or in the most superficial portion of the lung. The objective of this single-center, prospective study was to determine the prevalence of a variety of pleural and pulmonary US findings during routine breast US. METHODS: In this study, there were 200 women undergoing standard breast US examination. The presence of pleural and pulmonary abnormalities in these cases was recorded. Two off-site reviewers confirmed the presence of pleura and lung changes. RESULTS: There was no abnormal finding in 168 out of 200 cases (84%) while there were one or more abnormal findings in 32 cases (16%). Pleural effusion was observed in 0.5% of cases, thickening of the pleural line 5% of cases, irregularity of the pleural line in 6% of cases, increased number of vertical artifacts in 9% of cases, subpleural nodulations in 2% of cases, and lung consolidation in 0.5%. CONCLUSION: Pleural and lung changes are not uncommon during breast US. Operators performing breast US examinations should be aware of the possibility to identify unsuspected pleuro-pulmonary abnormalities.

High-resolution ultrasound approach to quadrangular joint in carpal boss: Everything musculoskeletal sonographer should know.

At the quadrangular joint (QAJ) of the carpus, a rare bony protuberance called carpal boss (CB) may occur. This bone abnormality may be due to osteophytes development or os styloideum. Symptomatic patients may complain pain, swelling, and restrictions in hand motion. These symptoms result from joint degenerative-inflammatory changes, development of ganglion cyst/bursitis, or tendons pathology. Correct diagnosis and appropriate management can be achieved through high-resolution ultrasonography (HR-US). The purpose of this review is to define the pathology spectrum around and within the QAJ in CB. The role of HR-US is highlighted and the standard technique for the QAJ assessment is described.

Aortic dissection: How to identify it during an abdominal ultrasound examination and achieve a potentially lifesaving diagnosis.

Aortic dissection (AD) is a rare and potentially fatal condition that may be diagnosed late. During an emergency or elective abdominal ultrasound (US) examination, when going to evaluate the abdominal aorta for other reasons, it may happen that we find ourselves suspecting an AD. It is therefore important to know the US characteristics of this pathology to avoid wrong or missed diagnoses. Here, we present our practical experience regarding the application of US in the study of the abdominal aorta, which allowed us on several occasions to find an unexpected dissection in patients brought to our attention for other reasons.

Multi-omics staging of locally advanced rectal cancer predicts treatment response: a pilot study.

Treatment response assessment of rectal cancer patients is a critical component of personalized cancer care and it allows to identify suitable candidates for organ-preserving strategies. This pilot study employed a novel multi-omics approach combining MRI-based radiomic features and untargeted metabolomics to infer treatment response at staging. The metabolic signature highlighted how tumor cell viability is predictively down-regulated, while the response to oxidative stress was up-regulated in responder patients, showing significantly reduced oxoproline values at baseline compared to non-responder patients (p-value < 10-4). Tumors with a high degree of texture homogeneity, as assessed by radiomics, were more likely to achieve a major pathological response (p-value < 10-3). A machine learning classifier was implemented to summarize the multi-omics information and discriminate responders and non-responders. Combining all available radiomic and metabolomic features, the classifier delivered an AUC of 0.864 (± 0.083, p-value < 10-3) with a best-point sensitivity of 90.9% and a specificity of 81.8%. Our results suggest that a multi-omics approach, integrating radiomics and metabolomic data, can enhance the predictive value of standard MRI and could help to avoid unnecessary surgical treatments and their associated long-term complications.

Understanding CEAP Classification: Insights from an Italian Survey on Corona Phlebectatica and Recurrent Active Venous Ulcers by Vascular Specialists.

Background and Objectives: The clinical relevance of "corona phlebectatica" and the management of risk factors for recurrence of venous ulcers in patients with chronic venous disease may be variable based on vascular specialists in different geographical areas of Italy. The aim of the present survey is to evaluate the management of patients with chronic venous disease by vascular specialists in different areas of the national territory. In particular, this involves ascertaining the clinical/prognostic relevance attributed to the presence of the "corona phlebectatica" as well as to the management of risk factors related to recurrence of venous ulcers. Materials and Methods: The web-based survey aimed at vascular medicine specialists with particular interest in venous disease. A questionnaire was developed, based on 12 questions, in relation to clinical assessment, risk factor management, and therapy in patients with chronic venous disease. Results: Almost all of the specialists involved actively participated in the survey, declaring that they personally manage chronic venous disease overall. There was a strong agreement in the prognostic consideration attributed to the presence of "corona phlebectatica" and to the management of risk factors for venous ulcer recurrence, regardless of the different geographical areas of interest. Conclusions: Accordingly with the results of this self-assessment survey, the skills and experience of the specialists involved appear to be of a good standard, both in the clinical evaluation and in the management of the progression of chronic venous disease. However, the need to reach more cultural insights into the correlations between chronic venous disease and risk factors correlated with disease progression emerges. Moreover, there was the need for a greater and tighter overall clinical control of a patient with chronic venous disease, also in relation to the presence of comorbidities.

Complications Subsequent to Urinary Tract Stent Placement: An Overview Focusing on the Imaging of Cancer Patients.

Ureteral involvement by a tumor is common, and both partial and complete obstructions can result in symptoms that are distressing and debilitating, especially in cancer patients for whom the resection of the primary tumor is not considered an option. Maintaining ureteric patency in these patients is a challenge. In addition, in cases where a patient has undergone nephroureterectomy due to primary transitional cell cancer, it becomes necessary to decompress the urinary tract to preserve the contralateral kidney from irreversible damage. This is possibly due to ureteral stenting, both retrograde and anterograde, and percutaneous nephrostomy (PCN). Since imaging plays an important role in the routine monitoring of stents, their more and more increasing use requires radiologists to be familiar with these devices, their correct position, their potential complications, and their consequences. The aim of this review is to offer a comprehensive review of the imaging features of some urinary stents and to show the complications encountered in cancer patients as a direct consequence of an invasive diagnostic or therapeutic procedure. Specifically, we focus on ureteral stents and PCN.

Ultrasound Imaging of the Sciatic Nerve.

The sciatic nerve (SN) is the biggest nerve in the human body and innervates a large skin surface of the lower limb and several muscles of the thigh, leg, and foot. It originates from the ventral rami of spinal nerves L4 through S3 and contains fibers from both the posterior and anterior divisions of the lumbosacral plexus. After leaving the neural foramina, the nerve roots merge with each other forming a single peripheral nerve that travels within the pelvis and thigh. Non-discogenic pathologies of the SN are largely underdiagnosed entities due to nonspecific clinical tests and poorly described imaging findings. Likewise, to the best of our knowledge, a step-by-step ultrasound protocol to assess the SN is lacking in the pertinent literature. In this sense, the aim of the present manuscript is to describe the normal sono-anatomy of the SN from the greater sciatic foramen to the proximal thigh proposing a standardized and simple sonographic protocol. Then, based on the clinical experience of the authors, a few tips and tricks have been reported to avoid misinterpretation of confounding sonographic findings. Last but not least, we report some common pathological conditions encountered in daily practice with the main purpose of making physicians more confident regarding the sonographic "navigation" of a complex anatomical site and optimizing the diagnosis and management of non-discogenic neuropathies of the SN.

"Daddy wrist": A high-resolution ultrasound diagnosis of de Quervain tenosynovitis.

De Quervain's tenosynovitis involves the first of the six dorsal compartments of the wrist, which contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. It seems to be associated with female sex (F:M = 10:1), middle age (30-50 years) and activities involving repetitive hand and wrist motions such as typing, piano playing or repetitively lifting children head, such as in postpartum females (hence the term "baby wrist" or "mommy wrist"). Aim of this paper was to illustrate high-resolution ultrasound (US) features of the DQD by describing a well-documented case that occurred in a "new dad" taking care of his babe. Hence, firstly in literature we could refer to this condition with the term of "daddy wrist".

Isolated adductor longus avulsion in a young semi-professional football player: Imaging contribution and therapeutic considerations.

Adductor longus injuries are usually observed at the proximal musculo-tendinous junction, but isolated tendinous ruptures (i.e., avulsion) at the origin on the pubic bone are uncommon. In this article, we report a new case of isolated adductor longus avulsion that occurred in a young athlete and was treated with conservative therapy. An 18 years old semi-professional football player, in the attempt to reach the ball with his right leg, reported acute pain and functional limitation in his left adductor area. Clinical examination showed tenderness on palpation associated with mild swelling. Manual strength testing of adductor muscles showed weakness and elicited moderate pain in the proximal groin region near the pubic bone. The diagnostic evaluations (ultrasound [3-14 MHz linear probe] and magnetic resonance imaging [1.5 Tesla magnetic field]), performed a few days after the event, showed a complete isolated avulsion of the proximal adductor longus tendon associated with a fluid collection, with a gap of about 9.5 mm from its insertion on the pubic bone. Degenerative alterations (sub-chondral sclerosis, bone edema, erosions, cortical irregularities, calcifications) were found. These findings were crucial in the treatment choice because conservative management is suggested when the gap is below 1 cm and when no important displacement of proximal torn tendon's end at dynamic ultrasound is appreciated. A structured rehabilitation protocol was implemented, allowing the player to come back to his full athletic activity after 146 days. Return to play was allowed when several subjective and objective parameters were fully satisfied (full hip range of motion, pain-free football-specific activities, less than a 5%-10% difference in hip adduction strength between the injured and uninjured legs, advanced anatomical healing of the adductor longus tendon seen on diagnostic exams, and Hip And Groin Outcome Score [HAGOS] scores similar to baseline data). This case report emphasizes the importance of diagnostic imaging and clinical assessments in the management of an adductor longus avulsion with short retraction (about 1 cm). Both imaging techniques are non-invasive and without risks, allow contra-lateral examination and may guide in the treatment choice; moreover, they significantly influence the post-care approach by enabling to fine-tune a safe return to full athletic activity with minor re-injury rate. While US can be used as primary imaging modality, MRI offers a higher level of accuracy.

MRI-Based Radiomics Approach Predicts Tumor Recurrence in ER + /HER2 - Early Breast Cancer Patients.

Oncotype Dx Recurrence Score (RS) has been validated in patients with ER + /HER2 - invasive breast carcinoma to estimate patient risk of recurrence and guide the use of adjuvant chemotherapy. We investigated the role of MRI-based radiomics features extracted from the tumor and the peritumoral tissues to predict the risk of tumor recurrence. A total of 62 patients with biopsy-proved ER + /HER2 - breast cancer who underwent pre-treatment MRI and Oncotype Dx were included. An RS > 25 was considered discriminant between low-intermediate and high risk of tumor recurrence. Two readers segmented each tumor. Radiomics features were extracted from the tumor and the peritumoral tissues. Partial least square (PLS) regression was used as the multivariate machine learning algorithm. PLS ß-weights of radiomics features included the 5% features with the largest ß-weights in magnitude (top 5%). Leave-one-out nested cross-validation (nCV) was used to achieve hyperparameter optimization and evaluate the generalizable performance of the procedure. The diagnostic performance of the radiomics model was assessed through receiver operating characteristic (ROC) analysis. A null hypothesis probability threshold of 5% was chosen (p < 0.05). The exploratory analysis for the complete dataset revealed an average absolute correlation among features of 0.51. The nCV framework delivered an AUC of 0.76 (p = 1.1∙10-3). When combining "early" and "peak" DCE images of only T or TST, a tendency toward statistical significance was obtained for TST with an AUC of 0.61 (p = 0.05). The 47 features included in the top 5% were balanced between T and TST (23 and 24, respectively). Moreover, 33/47 (70%) were texture-related, and 25/47 (53%) were derived from high-resolution images (1 mm). A radiomics-based machine learning approach shows the potential to accurately predict the recurrence risk in early ER + /HER2 - breast cancer patients.

Multiparametric Ultrasound Diagnostic Approach to Malignancy-Mimicking Adenomatoid Tumors of the Scrotum: Is Strain Elastography Enough?

Background: Paratesticular tumors (PTs) are very uncommon, accounting for almost 5% of intrascrotal tumors. Of these, adenomatoid tumors (ATs) represent about 30% and most frequently arise in the tail of the epididymis. Ultrasound (US) examination is the first-choice imaging method employed for the evaluation of the scrotum. Unfortunately, there are no specific US-imaging features useful for distinguishing an AT from a malignant lesion. To increase diagnostic accuracy and confidence, new sonographic techniques have incorporated real-time tissue elastography (RTE) under the assumption that malignant lesions are "harder" than benign lesions. Case report: In our paper, we describe a very rare case of a 60-year-old patient with a giant paratesticular mass mimicking malignancy when examined using RTE, i.e., it was stiffer than the surrounding tissue (a hard pattern), which, upon histologic examination, was identified as an AT. Discussion: Our case underscores that there is also a significant overlap between different types of scrotal lesions when RTE is used for examination. Thus, if a PT is found, the imaging approach should always be supplemented with more definitive diagnostic methods, such as FNAC or FNAB, which are the only diagnostic methods capable of leading to a certain diagnosis. Conclusions: Alongside underlining the importance of pre-operative imaging for making correct diagnoses and selecting the correct therapy, we wish to draw our readers' attention to this report in order to demonstrate the clinical implications of a giant AT presenting as stiff lesions when examined using SE.

Ablation of pulmonary neoplasms: review of literature and future perspectives.

Thermal ablation is a minimally invasive technology used to treat many types of tumors, including lung cancer. Specifically, lung ablation has been increasingly performed for unsurgical fit patients with both early-stage primi-tive lung cancer and pulmonary metastases. Image-guided available techniques include radiofrequency ablation, microwave ablation, cryoablation, laser ablation and irreversible electroporation. Aim of this review is to illustrate the major thermal ablation modalities, their indications and contraindications, complications, outcomes and notably the possible future challenges.

Congenital lung malformations: can we avoid computed tomography? A five-year study.

Purpose: Congenital lung malformations (CLMs) consist of a variety of pulmonary development disorders. In the CLM approach, computed tomography (CT) is considered the gold standard imaging technique due to the high-resolution for the lung parenchyma evaluation, the study of the vascular system after contrast injection, and the multiplanar reconstructions. In the paediatric population CT is considered too invasive due to ionizing radiation and the use of contrast agent. Therefore, the indications for the use of magnetic resonance imaging (MRI) are increasing. The aim of our study is to compare retrospectively MRI and CT in the evaluation of CLMs, to reduce or avoid the use of contrast-enhanced CT in the paediatric population. Material and methods: We retrospectively evaluated 22 paediatric patients with prenatal diagnosis of CLMs. All the patients underwent postnatal MRI in the first 2 weeks of life (except for a patient) and pre-surgery contrast-enhanced CT. A total of 7 blinded radiologists divided into 3 different groups independently reviewed each MRI and CT examination. Sensitivity and specificity of radiologists with different years of experience on the field, as well as of MRI findings regarding every pathology, were evaluated using a ROC curve. The interobserver agreement regarding the MRI findings was also measured. Results: Analysing the ROC curves, we observed that MRI provided a satisfactory accuracy for diagnosing most congenital pulmonary diseases. Conclusions: Our study showed that MRI without contrast agent allows us to reach a CLM diagnosis in good agreement with contrast-enhanced CT, which is considered the gold standard imaging technique.

Interventional Ultrasound in Dermatology: A Pictorial Overview Focusing on Cutaneous Melanoma Patients.

Cutaneous melanoma incidence is increasing worldwide, representing an aggressive tumor when evolving to the metastatic phase. High-resolution ultrasound (US) is playing a growing role in the assessment of newly diagnosed melanoma cases, in the locoregional staging prior to the sentinel lymph-node biopsy procedure, and in the melanoma patient follow-up. Additionally, US may guide a number of percutaneous procedures in the melanoma patients, encompassing diagnostic and therapeutic modalities. These include fine needle cytology, core biopsy, placement of presurgical guidewires, aspiration of lymphoceles and seromas, and electrochemotherapy.

Primary non-parasitic splenic cyst: US- and fluoroscopy-guided percutaneous management by alcohol sclerosis on six patients.

PURPOSE: This manuscript aims to report on a retrospective analysis of six patients treated with combined US- and fluoroscopic-guided percutaneous alcohol sclerosis for primary non-parasitic splenic cysts. METHODS: In this retrospective analysis, three females and three males affected by primary non-parasitic splenic cysts were included. All except one were symptomatic. Preoperative cyst diameter was in mean 113 mm (range: 67-210 mm). Ethanol 96% was adopted as sclerosant agent; the amount of ethanol injected corresponded to the 20%-30% of the cystic volume. US follow-up was planned at 2/4 weeks; MR follow-up was conducted almost at 6 months after the last treatment session. Technical success was considered as cyst disappearance or reduction of the maximum diameter <50 mm; clinical success, in those symptomatic cases, was considered as symptoms resolution or marked improvement. RESULTS: Eleven procedures had been performed: one in three patients, three in two patients and two in one patient. Technical success was 83.3%; clinical success was 80%. Only one patient, with a preoperative cystic diameter of 210 mm and despite three treatment sessions, had an increase in the cystic size and did not report symptoms improvement. CONCLUSIONS: In this sample, US-guided percutaneous alcohol sclerosis was a safe and effective spleen preserving option to treat primary non-parasitic splenic cysts.

Seeing the unseen with superb microvascular imaging: Ultrasound depiction of normal dermis vessels.

PURPOSE: Current color- and power-Doppler techniques cannot demonstrate vascularization of the dermis. Aim of this prospective study was to investigate whether the new superb vascular imaging (SMI) technique improves the ultrasound (US) depiction of dermis vessels in healthy volunteers. SMI was compared side-by-side to conventional power-Doppler (PD) imaging. METHODS: Thirty adult subjects (18 men and 12 women, mean age 45 years old) were evaluated with US at level of five body areas: forehead, forearm, palm, buttock, and thigh. The vascular index (VI) was employed to objectively quantify the difference between SMI and PD imaging in terms of dermis flow amount. RESULTS: Forehead VI was higher for SMI than for PD in 93% of cases, forearm VI was higher for SMI than for PD in 97% of cases, palm VI was higher for SMI than for PD in 87% of cases, buttock VI was higher for SMI than for PD in 100% of cases, thigh VI was higher for SMI than for PD in 100% of cases. SMI-detected vascular signals in 100% of the body areas. PD failed to show any flow signals from the forehead in 23% of cases, forearm in 37% of cases, palm in 33% of cases, buttock in 47% of cases, and thigh in 50% of cases. CONCLUSION: SMI can demonstrate normal dermis vascularization whereas conventional PD cannot. SMI is a sensitive and promising technique in the study of dermis abnormalities, particularly when quantifying the disease activity is important.

Atypical Sites of Lymphadenopathy after Anti-COVID-19 Vaccine: Ultrasound Features.

Background and Objectives: Several authors have reported cervical and axillary lymphadenopathies as known side effects following anti-COVID-19 vaccine administration. Few data are available about atypical locations of post-anti-COVID-19 vaccine lymphadenopathy. In this investigation, we evaluated the incidence and prevalence of postvaccine lymphadenopathy ultrasound (US) features in atypical sites. Materials and Methods: In this retrospective study, we retrospectively selected 64 patients on whom US was performed between January and October 2021 due to COVID-19 vaccine-related lymphadenopathy. We investigated lymph node anatomical sites, presence, number, size, shape, cortical profile, hilum outline, superb microvascular imaging (SMI), and elastosonography. Results: A total of 170 nodes were assessed. Atypical location was demonstrated in 5/64 patients (7.8%). In all these cases, atypical nodal involvement was associated with lymphadenopathy in a typical site (axillary, supraclavicular) ipsilateral to the vaccine injection site. Two patients presented lymphadenopathy in the infraclavicular station (3.1%), one in the pectoralis major muscle (1.6%), one in the left arm (1.6%), and one in the nuchal site (1.6%). All lymphadenopathies were oval-shaped, with a median size of 0.9 ± 0.2 cm. US features included a symmetric cortex with hilum evidence (4/6, 60%), vascular signal at SMI in both the hilar region and periphery of lymph node (5/6, 83.3%), and a US elastography pattern resembling that of adjacent tissues (5/6, 83.3%). The median age of patients with lymphadenopathies in an atypical location was 23 years. The main type of vaccine associated with lymph node appearance in atypical sites was Moderna's mRNA-1273 (60% of patients, 4/6 lymph nodes accounting for 66.7% among atypical locations). Conclusion: Post-COVID-19 vaccine administration lymphadenopathies in an atypical location represent an intense immune response to antigenic stimuli and they may show alarming US traits superimposed on malignant pathologies, which may complicate the patient's clinical and diagnostic pathway. Despite no distinctive US features between reactive post-COVID-19 vaccination and malignant lymph nodes being available, careful examination of atypical lymph node locations associated with accurate knowledge of patients' clinical background and delay of US exam to four to six weeks after vaccine injection should be considered.

Ultrasound-guided percutaneous irrigation of rotator cuff calcific tendinosis. What radiologist should know.

Rotator cuff calcific tendinopathy is a common condition caused by the presence of calcification into the rotator cuff or in the subacromial-subdeltoid bursa. The pathogenetic mechanism of this pathology is still debated. Calcific tendinitis frequently affects the rotator cuff and may cause shoulder pain and reduction of range of motion. It can be diagnosed with conventional radiography, ultrasound, or magnetic resonance imaging. The first therapeutic option includes conservative management based on rest, physical therapy, and oral non-steroid anti-inflammatory administration. Extracorporeal shock wave therapy is a noninvasive technique that can be useful for the fragmentation of calcific deposits. Imaging-guided percutaneous irrigation is currently considered the gold standard technique for the treatment of calcific tendinitis due to its minimal invasiveness and its success rate of about 80%.