Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer.

PURPOSE: This study was done to verify the usefulness of preoperative breast magnetic resonance (MR) imaging in patients with newly diagnosed breast cancer. MATERIALS AND METHODS: A retrospective analysis of 291 patients with invasive breast cancer newly diagnosed with conventional breast imaging (mammography and ultrasound) was performed. All patients underwent MR imaging prior to surgery. The MR imaging detection rate of additional malignant cancers occult to mammography and ultrasound was calculated. Data were analysed with Fisher's exact test (p<0.05) according to the following parameters: histopathological features of the index tumour (histological type and size) and mammographic density [according to the Breast Imaging Reporting and Data System (BI-RADS) classification from 1 fatty to 4 dense). The gold standard was the histological examination on the surgical specimen. RESULTS: MR imaging identified 40 mammographically and sonographically occult malignant lesions other than the index cancer in 27/291 patients (9%). These additional cancers were located in the same quadrant as the index cancer in 13 women (4%), in a different quadrant in 12 (4%) and in the contralateral breast in the remaining two (1%). The cancer detection rate in the subgroup of index cancers with lobular histological type was 25%, significantly higher (p=0.03) than the detection rate of 11% recorded in the subgroup of ductal cancers. The cancer detection rate in the subgroup of index cancers >2 cm was 27%, significantly higher (p=0.001) than the rate of 8% found in the subgroup of index cancers <2 cm. Mammographic density was not correlated (p=0.48) with MR detection of additional cancer, with 14% of additional malignancies being detected in both dense and fatty breasts. CONCLUSIONS: In patients with newly diagnosed invasive breast cancer, preoperative MR imaging is useful for detecting additional synchronous malignancies that are not detected on conventional breast imaging. The cancer detection rate is 9%. The use of preoperative MR imaging as an adjunct to conventional breast imaging in women with an infiltrating lobular index cancer and an index cancer >2 cm is especially beneficial.

Comparison between different kernel reformatting filters in 3D quantitative analysis of MDCT coronary angiography.

PURPOSE: Coronary angiography with multidetector-row computed tomography (MDCT-CA) allows quantification of coronary artery stenosis with a high level of accuracy; however, a better estimation of stenosis can be achieved by using appropriate reformatting filters, especially in stents and calcified segments. Quantitative computed tomography angiography (QCTA) is intended to overcome the limitations of the visual score. The aim of this study was to evaluate the accuracy of QCTA with different filters in comparison with quantitative coronary angiography (QCA) and visual score. MATERIALS AND METHODS: Two blinded operators visually scored 17 consecutive patients referred for MDCT-CA with a per-segment analysis. The degree of stenosis was classified as 0-20%, 20-50% (wall irregularities), 50-70% (significant disease) and 70-100% (vessel occlusion). Each segment was then analysed using the electronic callipers of the QCTA system with 15 different filters. No contour editing was performed. Data were compared with QCA and conventional coronary angiography (CCA). Comparison between QCTA, visual score and QCA were performed using Spearman's rank correlation. RESULTS: Of 25 segments analysed (mean 1.4 diseased segment per patient), 375 measurements were considered. Good correlation was found between the visual score and QCA [Pearson correlation coefficient (rho=0.852; p<0.0001)] and between QCA and CCA (rho=0.804; p<0.0001). Moderate correlation was found between QCA and QCTA only using two filters (rho=0.444; p<0.0001 for YA filter and rho=0.450; p<0.0001 for YB filter). CONCLUSIONS: Overall QCTA accuracy is low if contour editing is not applied, especially in calcified vessels. Certain filters can help to better estimate the exact percentage of stenosis.

Evaluation of colonic involvement in endometriosis: double-contrast barium enema vs. magnetic resonance imaging.

BACKGROUND: The purpose of the study was to compare the accuracy of double-contrast barium enema (DCBE) and magnetic resonance imaging (MRI) in the diagnosis of intestinal endometriosis using the histological examination on resected specimen as comparative standard. METHODS: Eighty-three consecutive patients with suspected intestinal endometriosis, resected between 2005 and 2007, were prospectively evaluated. All of the women underwent preoperative DCBE and MRI on the same day. We evaluated number, site (rectum, sigmoid, cecum), and size of the lesions. The imaging findings were correlated with those resulting at pathology. RESULTS: Among the 65 women who underwent surgery, 50/65 (76.9%) were found to have bowel endometriosis, with 9/50 (18%) patients presenting two lesions; DCBE allowed to detect 50/59 (84.7%) lesions. MRI allowed to detect 42/59 (71.1%) lesions. DCBE showed sensibility, specificity, PPV, NPV, and accuracy of respectively 84.7, 93.7, 98.0, 62.5, and 86.6%, MRI of 71.1, 83.3, 93.3, 46.8, and 74.6%. CONCLUSION: DCBE is more accurate than unenhanced MRI in the diagnosis of bowel endometriosis, and should be preferred in the preoperative management of this disease, since it usually enables a proper surgical planning.

MR imaging findings of elastofibroma dorsi in correlation with pathological features: our experience.

PURPOSE: This paper describes the role of magnetic resonance (MR) imaging for characterising elastofibroma dorsi in correlation with pathological findings. MATERIALS AND METHODS: Over a period of 9 years, 1,233 MR examinations of the periscapular region assessed for the presence of elastofibroma dorsi with superconductive 1.5-T MR scanners at three different radiology institutes were retrospectively reviewed. RESULTS: Our study population included 15 patients (12 women, three men; mean age 58 years, range 28-82 years) presenting with 17 lesions. Two patients had bilateral elastofibroma dorsi. Thirteen of 15 patients underwent MR examination for clinical suspicion of a lesion located in the periscapular region, whereas in 2/15 cases it was an incidental finding during MR examination performed for other diseases. Diagnosis of elastofibroma dorsi was confirmed by histopathology in 11/17 cases. The remaining lesions were considered benign, as their size and morphology did not change over a mean follow-up period of 1.5 years. CONCLUSIONS: MR imaging with its multiplanar capabilities and high-contrast resolution has a high level of accuracy in characterising elastofibroma dorsi and may avoid the need for biopsy or surgical operation.

Cardiac computed tomography in the evaluation of left anterior descending coronary artery with vein patch reconstruction.

PURPOSE: This study evaluated the morphological and functional results of surgical reconstruction of the left anterior descending (LAD) coronary artery with an autologous vein patch, associated with left internal mammary artery (LIMA) grafting onto the patch. MATERIALS AND METHODS: Cardiac computed tomography (CT) images were assessed in terms of functional and morphological parameters. Function was evaluated by assessing patency at 36 months of the reconstructed LAD (based on the attenuation of the native vessel distal to the anastomosis). Morphology was evaluated by studying vein-patch diameters, profiles and margins, shape and structure to categorise the patches into three groups (A, B, C). Within 1 month of CT, all patients underwent functional testing (bicycle ergometry). RESULTS: CT imaging correctly depicted the LAD graft, revealing it to be fully patent in all cases. On the basis of our morphological classification, 21 patients were classed as group A, two as group B and two as group C. At bicycle ergometry, 23 patients were negative and two were positive. Group C patients had the worst functional results. CONCLUSIONS: Cardiac CT allowed adequate evaluation of the LAD graft patency and morphology, and in consideration of its noninvasive nature, it may become the imaging tool of choice for evaluating extended LAD reconstruction.

Radiation dose saving through the use of cone-beam CT in hearing-impaired patients.

PURPOSE: Bionic ear implants provide a solution for deafness. Patients treated with these hearing devices are often children who require close follow-up with frequent functional and radiological examinations; in particular, multislice computed tomography (MSCT). Dental volumetric cone-beam CT (CBCT) has been reported as a reliable technique for acquiring images of the temporal bone while delivering low radiation doses and containing costs. The aim of this study was to assess, in terms of radiation dose and image quality, the possibility of using CBCT as an alternative to MSCT in patients with bionic ear implants. MATERIALS AND METHODS: One hundred patients (mean age 26 years, range 7-43) with Vibrant SoundBridge implants on the round window underwent follow-up: 85 with CBCT and 15 with MSCT. We measured the average tissue-absorbed doses during both MSCT and CBCT scans. Each scan was focused on the temporal bone with the smallest field of view and a low-dose protocol. In order to estimate image quality, we obtained data about slice thickness, high- and low-contrast resolution, uniformity and noise by using an AAPM CT performance phantom. RESULTS: Although the CBCT images were qualitatively inferior to those of MSCT, they were sufficiently diagnostic to allow evaluation of the position of the implants. The effective dose of MSCT was almost three times higher than that of CBCT. CONCLUSIONS: Owing to low radiation dose and sufficient image quality, CBCT could be considered an adequate technique for postoperative imaging and follow-up of patients with bionic ear implants.

Autoimmune pancreatitis: imaging findings on contrast-enhanced MR, MRCP and dynamic secretin-enhanced MRCP.

PURPOSE: This study retrospectively determined magnetic resonance (MR), MR cholangiopancreatography (MRCP) and secretin-MRCP findings in patients with autoimmune pancreatitis (AIP). MATERIALS AND METHODS: The MR examinations of 28 patients with histopathologically proven AIP were reviewed. In 14 cases, secretin-enhanced MRCP was performed. The observers evaluated pancreatic parenchymal enlargement, signal intensity abnormalities, enhancement, vascular involvement, bile-duct diameter and main pancreatic duct (MPD) narrowing (diffuse/focal/segmental). After secretin administration, the presence of the "duct-penetrating" sign was evaluated. RESULTS: MR imaging showed diffuse pancreatic enlargement in 8/28(29%) cases, focal pancreatic enlargement in 16/28 (57%) cases and no enlargement in 4/28 (14%) cases. The alteration of pancreatic signal intensity was diffuse in 8/28 (29%) cases (eight diffuse AIP) and focal in 20/28 (71%) cases (20 focal AIP). Delayed pancreatic enhancement was present in all AIP, with peripheral rim of enhancement in 8/28 (29%) AIP (1/8 diffuse, 7/20 focal); vascular encasement was present in 7/28 (25%) AIP (1/8 diffuse, 6/20 focal); distal common bile duct narrowing was present in 12/28(43%) AIP (5/8 diffuse, 7/20 focal). MRCP showed MPD narrowing in 17/28 (61%) AIP (4/8 diffuse, 15/20 focal), MPD dilation in 8/28(29%) AIP (3/8 diffuse, 5/20 focal) and normal MPD in 1/8 diffuse AIP. Secretin-MRCP showed the duct-penetrating sign in 6/14(43%) AIP (one diffuse AIP with MPD segmental narrowing, five focal AIP with MPD focal narrowing), demonstrating integrity of the MPD. CONCLUSIONS: Delayed enhancement and MPD stenosis are suggestive for AIP on MR and MRCP imaging. Secretin-enhanced MRCP is a problem-solving tool in the differential diagnosis between focal AIP and ductal adenocarcinoma.

Choice strategy of different dose-saving protocols in 64-slice MDCT coronary angiography.

PURPOSE: Multidetector-row computed tomography coronary angiography (MDCT-CA) produces high-level radiation dose because of submillimetre slice thickness and short scan time. As a result, manufacturers have produced different dose-saving protocols that may, however, reduce image quality and thus diagnostic accuracy. The aim of our study was to assess the diagnostic quality of MDCT-CA using different dose-saving protocols. MATERIALS AND METHODS: Between April and August 2008, we examined 65 patients with 64-slice MDCT-CA: 6/65 using the step-and-shoot dose-saving protocol, 45/65 the cardiac dose right protocol and 14/65 using a standard protocol. Image quality was evaluated on a per-patient and per-segment basis, and the effective dose of each protocol was recorded. RESULTS: In the per-patient analysis, image quality was excellent in 100% of the step-and-shoot protocols, in 91.1% of the cardiac dose right protocols and in 85.8% of the standard protocols. Effective dose to the patient considering the whole study (i.e. scout, calcium score, triggering and MDCT-CA) was 20.49 mSv in the standard protocol, 14.8 mSv in the cardiac dose right protocol and 6.63 mSv in the step-and-shoot protocol. CONCLUSIONS: The radiologist should apply the appropriate protocol in relation to the clinical indications, type of patient and information required in order to spare as much dose as possible while maintaining high image quality.

Malignant focal liver lesions at contrast-enhanced ultrasonography and magnetic resonance with hepatospecific contrast agent.

The aim of this study was to compare the diagnostic accuracy of the late phase of CEUS and the hepatobiliary phase of CE-MR with Gd-BOPTA in the characterization of focal liver lesions in terms of benignity and malignancy. A total of 147 solid focal liver lesions (38 focal nodular hyperplasias, 1 area of focal steatosis, 3 regenerative nodules, 8 adenomas, 11 cholangiocarcinomas, 36 hepatocellular carcinomas and 49 metastases) were retrospectively evaluated in a multicentre study, both with CEUS, using sulphur hexafluoride microbubbles (SonoVue, Bracco, Milan, Italy) and CE-MR, performed with Gd-BOPTA (Multihance, Bracco, Milan, Italy). All lesions thought to be malignant were cytohistologically proven, while all lesions thought to be benign were followed up. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and accuracy were calculated for the late phase of CEUS and the hepatobiliary phase of CE-MRI, respectively, and in combination. Analysis of data revealed 42 benign and 105 malignant focal liver lesions. We postulated that all hypoechoic/hypointense lesions on the two phases were malignant. The diagnostic errors were 13/147 (8.8%) by CEUS and 12/147 (8.2%) by CE-MR. Sensitivity, specificity, PPV, NPV and accuracy of the late phase of CEUS were 90%, 93%, 97%, 80% and 91%, 93%, 97%, 81% and 92% for the hepatobiliary phase of CE-MRI, respectively. If we considered both techniques, the misdiagnosis diminished to 3/147 (2%) and sensitivity, specificity, PPV, NPV and accuracy were 98%, 98%, 99%, 95% and 98%. The combination of the late phase of CEUS and the hepatobiliary phase of CE-MR in the characterization of solid focal liver lesions in terms of benignity and malignancy is more accurate than the two techniques used separately.

E-learning in radiology: an Italian multicentre experience.

OBJECTIVE: The aim of this study was to design, deliver and evaluate an e-learning teaching programme for post-graduate radiodiagnostics training that would involve various post-graduate schools throughout Italy. MATERIALS AND METHODS: All of the Directors of Italian post-graduate schools of radiodiagnostics were sent an e-mail on 27 September 2010 informing them of our willingness to set up an e-learning project for the academic year 2010-2011 in the form of single-subject teaching seminars. The proposed subjects were the semeiotics of the various organs and apparatuses in the context of "Urgent/Emergency Pathology". After having received registrations, a calendar of lessons was planned to be held between 10 November 2010 and 12 October 2011. The validity of the project was tested by means of a multiple-choice questionnaire covering the technical and didactic quality of the entire project, to be completed by the students. RESULTS: Fifty-one percent of the universities in Italy participated in the project: Trieste, Udine, Verona, Milan-Bicocca, Novara, Varese, Genoa, Sassari, Rome Campus, the Catholic University of Rome, Chieti, Foggia, Catania, Modena, Florence, Palermo, Bologna, Pavia, Parma and Ferrara. The lessons were attended by a total of 10,261 post-graduate medical students, for an average of 513.1 students per lesson. Seventy percent of the students judged the didactic content "excellent", 25% "good", and 5% "satisfactory"; none said it was unsatisfactory. In terms of visual quality (particularly the details of the radiological images proposed in the form of slides and/or video clips), 73% judged it "excellent", 20% "good", 6% "satisfactory", and 1% "poor". The audio quality was judged "excellent" by 71%, "good" by 22%, "satisfactory" by 6% and "poor" by 1%. In relation to judgement of audio and video quality, it has to be underlined that this was greatly affected by the hardware/software configuration and the band speed and technology of the Internet connection. CONCLUSIONS: Technological evolution is overcoming all barriers, and technology is also having a positive impact on the approach to teaching. Our multicentre teaching experience merits the following considerations: the quality of the teaching product was certified by the students' judgements of its didactic content and the quality of reception; the economic cost of the teaching had a minimal impact on the post-graduate schools (€ 18 per lesson). In terms of breaking down national barriers, it is to be hoped that the coordination and integration of diagnostic imaging e-learning projects, with the participation of post-graduate schools in different European countries, can be developed not only in a spirit of "cultural sharing" and the exchange of teaching experiences.

Acoustic radiation force impulse (ARFI) ultrasound imaging of pancreatic cystic lesions.

PURPOSE: To evaluate the ARFI ultrasound imaging with Virtual Touch tissue quantification in studying pancreatic cystic lesions, compared with phantom fluid models. MATERIALS AND METHODS: Different phantom fluids at different viscosity or density (water, iodinate contrast agent, and oil) were evaluated by two independent operators. From September to December 2008, 23 pancreatic cystic lesions were prospectively studied. All lesions were pathologically confirmed. RESULTS: Non-numerical values on water and numerical values on other phantoms were obtained. Inter-observer evaluation revealed a perfect correlation (rs=1.00; p<0.0001) between all measurements achieved by both operators per each balloon and fluid. Among the pancreatic cystic lesions, 14 mucinous cystadenomas, 4 pseudocysts, 3 intraductal papillary-mucinous neoplasms and 2 serous cystadenomas were studied. The values obtained ranged from XXXX/0-4,85 m/s in mucinous cystadenomas, from XXXX/0-3,11 m/s in pseudocysts, from XXXX/0-4,57 m/s in intraductal papillary-mucinous neoplasms. In serous cystadenomas all values measured were XXXX/0m/s. Diagnostic accuracy in benign and non-benign differentiation of pancreatic cystic lesions was 78%. CONCLUSIONS: Virtual Touch tissue quantification can be applied in the analysis of fluids and is potentially able to differentiate more complex (mucinous) from simple (serous) content in studying pancreatic cystic lesions.

The diagnostic contribution of CT volumetric rendering techniques in routine practice.

Computed tomography (CT) volumetric rendering techniques such as maximum intensity projection (MIP), minimum intensity projection (MinIP), shaded surface display (SSD), volume rendering (VR), and virtual endoscopy (VE) provide added diagnostic capabilities. The diagnostic value of such reconstruction techniques is well documented in literature. These techniques permit the exploration of fine anatomical detail that would be difficult to evaluate using axial reconstructions alone. Although these techniques are now widely available, many radiologists are either unfamiliar with them or do not fully utilize their potential in daily clinical practice. This paper is intended to provide an overview of the most common CT volumetric rendering techniques and their practical use in everyday diagnostics.

Is intraoperative ultrasound (IOUS) still useful for the detection of liver metastases?

PURPOSE: To evaluate the clinical impact of intraoperative ultrasound (IOUS) in the detection of liver metastases during the years, as compared with those of other imaging modalities. MATERIALS AND METHODS: All IOUS scans performed for detection of liver metastases from 2000 to 2006 were retrospectively reviewed and compared with the results of preoperative imaging modalities: Ultrasound (US), Computed Tomography (CT), and/or Magnetic Resonance (MR). The number of cases in which IOUS and preoperative imaging studies produced discordant results, in terms of presence/absence of focal liver lesions, was calculated per year. Statistical analysis was performed using the McNemar test. A p value < 0.05 was considered statistically significant. RESULTS: Eighty-three IOUS scans performed in 2000-2003 were reviewed, and discordance with preoperative imaging findings was found in 19/83 (23%) cases. Of the 42 IOUS scans done during the 2004-2006 period, 10/42 (24%) showed discordance with preoperative studies. All metastases diagnosed with imaging studies were pathologically confirmed. The number of discordant cases in the two periods were not significantly different (p = 0.2). CONCLUSION: IOUS is still useful in the detection of liver metastases. Its decreased use is probably due to the improved accuracy of preoperative imaging modalities.

Resectable pancreatic adenocarcinoma: is the enhancement pattern at contrast-enhanced ultrasonography a pre-operative prognostic factor?

The aim of our study was to determine whether the enhancement pattern of pancreatic adenocarcinoma at contrast-enhanced ultrasonography (CEUS) is related to patient prognosis after resection. CEUS of 42 resected adenocarcinomas were retrospectively reviewed. Tumors were divided into two groups: group A=poorly vascularized (presence of avascular areas) or group B=well vascularized (absence of avascular areas). All lesions were resected and underwent pathological examination assessing tumor differentiation as: undifferentiated (poorly differentiated) or differentiated (moderately and well differentiated). Mean vascular density (MVD) was also evaluated. CEUS enhancement and pathology were correlated (Spearman's test). Survival was analyzed with the Kaplan-Meier method. Multivariate analysis was performed with the Cox regression model. There were 30 differentiated and 12 undifferentiated adenocarcinomas at pathology. At CEUS, 10 lesions were poorly vascularized, whereas 32 lesions were well vascularized. Positive correlation was observed between CEUS groups and tumoral differentiation (rs=0.51; p=0.001) and between CEUS and MVD (rs=0.74; p<0.0001). Median survival in patients with group A vascularization at CEUS was significantly lower than in group B (p=0.015). Cox proportional hazard model revealed the presence of poorly vascularized tumor at CEUS (p=0.0001) as a predictor of higher mortality. In conclusion, CEUS enables accurate depiction of the vascularization of adenocarcinoma, with positive correlation to histology grade and MVD.

Focal liver lesions in cirrhosis: value of contrast-enhanced ultrasonography compared with Doppler ultrasound and alpha-fetoprotein levels.

PURPOSE: This study aimed to evaluate the diagnostic value of contrast-enhanced ultrasound (CEUS) in characterising focal liver lesions in cirrhosis and to validate its use in lesions discovered during surveillance for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Between 2003 and 2006, 128 cirrhotic patients with focal liver lesions at baseline ultrasonography (US) were studied by power colour Doppler US (Doppler US) and CEUS. Serum alpha-fetoprotein (AFP) levels were assessed in all patients. Fine-needle biopsy or other reference modalities such as computed tomography (CT), magnetic resonance imaging (MRI) or digital subtraction angiography (DSA) were used as the gold standard. The accuracy of baseline US, Doppler US, AFP levels, combined US and AFP levels and combined US, Doppler US and CEUS in characterising focal liver lesions was assessed. Diagnostic performance was compared using the McNemar test. RESULTS: A total of 207 focal liver lesions (101 benign and 106 malignant) were identified in 128 patients. CEUS sensitivity and specificity for lesion characterisation were 96.2% and 97.0%, respectively, whereas its positive and negative predictive values were 97.1% and 96.1%. CEUS accuracy was 96.6%, higher than that of US (72.0%), Doppler US (70.0%), AFP levels (65.7%), combined US and Doppler US (70.0%) and combined US and AFP levels (90.3%). The differences between US and CEUS were statistically significant (p<0.05). CONCLUSIONS: CEUS can characterise focal liver lesions with 96.6% accuracy, a value higher than US, Doppler US, AFP levels, combined US and AFP levels and combined US and Doppler US. CEUS should therefore be used to characterise focal liver lesions detected during HCC surveillance of cirrhotic patients.

Spectrum of collateral findings in multislice CT coronary angiography.

PURPOSE: The aim of the study was to investigate the prevalence of the noncardiac collateral findings during multislice computed tomography coronary angiography (MSCT-CA). MATERIALS AND METHODS: Six hundred and seventy patients undergoing MSCT-CA with 16-slice and 64-slice CT scanners for suspected atherosclerotic disease of the coronary arteries were retrospectively reviewed. All data sets obtained with a large field of view (FOV) were analysed by two radiologists using standard mediastinal and lung window settings. Collateral findings were divided according to clinical importance into nonsignificant, remarkable and compulsory to be investigated. RESULTS: Eighty-five percent of patients revealed coronary artery disease (CAD). Only 138/670 (20.6%) were without any additional finding. An additional 1,234 findings were recorded: nonsignificant 332 (26.9%), mild 821 (66.53%), compulsory for study 81 (6.56%). A total of 81 patients (12.08%) had significant noncardiac pathology requiring clinical or radiological follow-up. Among these, newly discovered pathologies were revealed in two patients (2.46%). CONCLUSIONS: A significant number of noncardiac findings might have been missed in MSCT-CA scans; the appropriate approach should be as a team trained in cardiology and radiology.

Branch duct IPMTs: value of cross-sectional imaging in the assessment of biological behavior and follow-up.

Branch duct intraductal papillary mucinous tumors (IPMTs) are increasingly being described and represent a challenge for the physician. Recent imaging modalities, especially computed tomography and magnetic resonance, allow for a correct diagnosis, but IPMTs can manifest with different degrees of cellular atypia so it is very important to be able to establish the biological behavior of the lesion. Sixty-five patients were included in this study: 29 of them underwent surgery, and the other 36 were followed with cross-sectional imaging. Among patients who underwent surgery, 11 had benign lesions and 18 had malignant lesions. Overall sensitivity, specificity, and accuracy in the diagnosis of malignancy for all the cross-sectional imaging techniques were 61%, 81%, and 69%, respectively. Among patients who were followed and had a magnetic resonance cholangiopancreatographic diagnosis of branch duct IPMT with imaging features indicative of benignity, only two showed modifications over the follow-up period. Even considering some important biases (small number of patients and relatively short follow-up), interesting conclusions can be drawn: the imaging diagnosis of malignancy can be trusted, whereas that of benignity cannot be relied upon, but if the signs of malignancy are absent, the slow growth of the lesions justifies watchful follow-up in the correct clinical setting.

Focal liver lesions: sinusoidal phase of CEUS.

Ultrasound examination is the first imaging modality for hepatic study in neoplastic and chronic liver diseases. Focal liver lesions frequently cause diagnostic problems in terms of characterization, especially when small and hypoechoic to the rest of the parenchyma. Contrast--enhanced ultrasonography (CEUS) has shown its value in the characterization of focal liver lesions. This study assessed the value of the sinusoidal phase of CEUS with a second-generation contrast agent in the characterization of focal liver lesions to distinguish benign from malignant. Two hundred hepatic lesions with suspicious features at baseline ultrasound were prospectively studied with CEUS. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy of the sinusoidal phase in the characterization of benign versus malignant liver lesions were evaluated. Hypoechogenicity of the focal liver lesion, during the sinusoidal phase of CEUS, allowed the diagnosis of malignancy with a sensitivity of 85%, specificity of 88%, positive predictive value of 92%, negative predictive value of 77%, and diagnostic accuracy of 86%. The diagnostic confidence in the diagnosis of malignancy significantly increased, with receiver operating characteristic curve areas from 0.536 for baseline ultrasound to 0.902 for the sinusoidal phase of CEUS.