Prevalence and clinical significance of incidental extra-intestinal findings in MR enterography: experience of a single University Centre.

PURPOSE: To determine the incidence and clinical relevance of extra-intestinal incidental findings (IF) in a cohort of patients with proven or suspected Crohn disease (CD) examined with magnetic resonance enterography (MR-E) in a single University Centre. METHODS: Between January 2018 and June 2019, 182 patients with proven or suspected CD with a planned first MR-E examination, were retrospectively included in this study. Incidental findings were considered as any abnormality identified in the absence of previous clinically suspected or known disease. IF were categorized as unremarkable, benign or potentially relevant findings requiring further imaging or specific treatment. RESULTS: Of the 182 revised MR-E, extra-intestinal IF were recorded in 70 cases (38.5%); 35 (50%) incidental lesions were recognized as non-significant, 24 (34%) as benign and 11 (16%) as clinically relevant. Moreover, there was a positive correlation between IF and patients' age (p < 0.0001). CONCLUSIONS: In our experience, a high number of IF (38.5%) was found, with a prevalence that increases with patients' age. Clinically relevant findings were found in 16% of MR-E. This means that MR-E is a useful tool to detect IF, therefore, the presence of a radiologist during the image acquisition is crucial in adding sequences to the examination.

CT pulmonary angiography appropriateness in a single emergency department: does the use of revised Geneva score matter?

PURPOSE: To assess the percentage of computed tomography pulmonary angiography (CTPA) procedures that could have been avoided by methodical application of the Revised Geneva Score (RGS) coupled with age-adjusted D-dimer cut-offs rather than only clinical judgment in Emergency Department patients with suspected pulmonary embolism (PE). MATERIAL AND METHODS: Between November 2019 and May 2020, 437 patients with suspected PE based on symptoms and D-dimer test were included in this study. All patients underwent to CTPA. For each patient, we retrospectively calculated the age-adjusted D-dimer cut-offs and the RGS in the original version. Finally, CT images were retrospectively reviewed, and the presence of PE was recorded. RESULTS: In total, 43 (9.84%) CTPA could have been avoided by use of RGS coupled with age-adjusted D-dimer cut-offs. Prevalence of PE was 14.87%. From the analysis of 43 inappropriate CTPA, 24 (55.81%) of patients did not show any thoracic signs, two (4.65%) of patients had PE, and the remaining patients had alternative thoracic findings. CONCLUSION: The study showed good prevalence of PE diagnoses in our department using only physician assessment, although 9.84% CTPA could have been avoided by methodical application of RGS coupled with age-adjusted D-dimer cut-offs.

Standard high-resolution pelvic MRI vs. low-resolution pelvic MRI in the evaluation of deep infiltrating endometriosis.

OBJECTIVE: To compare the capabilities of standard pelvic MRI with low-resolution pelvic MRI using fast breath-hold sequences to evaluate deep infiltrating endometriosis (DIE). METHODS: Sixty-eight consecutive women with suspected DIE were studied with pelvic MRI. A double-acquisition protocol was carried out in each case. High-resolution (HR)-MRI consisted of axial, sagittal, and coronal TSE T2W images, axial TSE T1W, and axial THRIVE. Low-resolution (LR)-MRI was acquired using fast single shot (SSH) T2 and T1 images. Two radiologists with 10 and 2 years of experience reviewed HR and LR images in two separate sessions. The presence of endometriotic lesions of the uterosacral ligament (USL), rectovaginal septum (RVS), pouch of Douglas (POD), and rectal wall was noted. The accuracies of LR-MRI and HR-MRI were compared with the laparoscopic and histopathological findings. RESULTS: Average acquisition times were 24 minutes for HR-MRI and 7 minutes for LR-MRI. The more experienced radiologist achieved higher accuracy with both HR-MRI and LR-MRI. The values of sensitivity, specificity, PPV, NPV, and accuracy did not significantly change between HR and LR images or interobserver agreement for all of the considered anatomic sites. CONCLUSIONS: LR-MRI performs as well as HR-MRI and is a valuable tool for the detection of deep endometriosis extension. KEY POINTS: • High- and low-resolution MRI perform similarly in deep endometriosis evaluation • Low-resolution MRI significantly reduces the duration of the examination • Radiologist experience is fundamental for evaluating deep pelvic endometriosis.

[Chronic pancreatitis: which is the role of 320-row CT for the staging?]. / Pancreatite cronica: quale ruolo per la TC a 320 strati nella stadiazione?

The purpose of this study was to evaluate the diagnostic potential of multi-planar and volumetric reconstructions obtained from isotropic data by using 16-slice computed tomography (CT) in the diagnosis and staging of chronic pancreatitis. In a group of 42 patients CT images were evaluated searching for alterations in morphology and structure of the pancreas, alterations of the Wirsung duct, dilatation of the bile ducts, fluid collections, and vascular involvement of the digestive tract. The disease was then staged in mild, moderate and severe and correlated with the clinical staging. CT allowed the recognition of chronic pancreatitis in all cases. The staging was correct in 25/42 patients, with an accuracy rate of 59.5%. In the staging of moderate and severe forms, CT correlation with clinical and laboratory data was valid, but in mild forms it appeared less significant. Multi-detector CT is accurate in the recognition of moderate, advanced forms of chronic pancreatitis and in the identification of its complications, while it is poorly correlated with the clinical staging in mild forms of the disease.

[Pulmonary arteriovenous fistulas in patients with hereditary hemorrhagic telangiectasia: role of MR angiography]. / Fistole artero-venose polmonari in pazienti con teleangiectasia emorragica ereditaria: ruolo dell'angio-RM.

The aim of this work is to establish the accuracy of pulmonary magnetic resonance angiography (MRA) compared to multidetector computed tomography (MDCT) and pulmonary angiography in the diagnostic evaluation of pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia. Eight consecutive patients underwent MRA, MDCT and pulmonary angiography. All patients were carriers of PAVMs amenable to endovascular treatment. The parameters we have evaluated were the presence, the number of fistulas and the diameter of the feeding artery of the malformation. In all cases, the findings of the three tests were comparable. In only one case, MR images were considered qualitatively poorer than MDCT, although sufficient for the recognition of the lesion located in the hilum. The diameters of the arteries showed no statistically differences between MRA and CT. In conclusion, the MRA technique was found to be valid and reliable in the diagnosis of PAVMs in patients with HHT.

[Role of multidetector CT in the evaluation of large bowel obstruction]. / Ruolo della TC multidetettore nelle occlusioni del grosso intestino.

The aim of the study was to assess the accuracy of multidetector CT (MDCT) with MPR reformation in the evaluation of large bowel obstruction. Thirty-one patients were evaluated retrospectively in a blinded fashion by two radiologists. All patients underwent MDCT with multiplanar reformation (MPR). The two radiologists interpreted independently the axial images and then the reconstructions. Each patient received a score from 1 (absent occlusion) to 5 (confirmed occlusion). The results were compared with surgical findings. Both axial and MPR images showed a very high accuracy in the diagnosis of bowel obstruction with a significant advantage of MPRs over native images and without any difference between the two radiologists. MDCT is an accurate technique in the evaluation of large bowel obstruction and use of MPRs facilitates the interpretation of imaging findings.

[Gatrointestinal imaging with multidetector CT and MRI]. / Tecniche di studio dell'apparato digerente con TC e RM.

Computed tomography (CT) and magnetic resonance imaging (MRI) are important diagnostic tools for evaluating gastrointestinal disorders. A rigorous examination protocol is needed to achieve the best results. This paper describes the technical issues of CT and MRI for the study of gastrointestinal tracts (esophagus, stomach, small and large bowel).

[Multidetector CT for the assessment of the groin region]. / La TC multidetettore nello studio del canale inguinale.

Assessment of the complex anatomy of the groin region using different imaging modalities is important to identify those pathological conditions that may present with atypical symptoms. In obese patients or in the presence of complications, physical examination may be unremarkable and instrumental studies based on non-invasive techniques (e.g., ultrasounds) do not allow accurate assessment of this region. Multidetector CT scanning and reconstruction can provide useful information on inguinal canal anatomy and its related diseases, contributing to timely therapeutic interventions.

Diagnosis of colorectal endometriosis: contribution of contrast enhanced MR-colonography.

OBJECTIVE: To investigate the contribution of contrast-enhanced MR-colonography (CE-MR-C) for the diagnosis of intestinal endometriosis. METHODS: One hundred and four women with suspected endometriosis were prospectively enrolled. All patients were subjected to MRI consisting of two phases: pelvic high-resolution MRI (HR-MRI) followed by CE-MR-C after colonic distension using a 1.5-liter water enema and injection of 0.15 ml/kg of 0.5 M gadolinium-DTPA with T1w high-resolution isotropic volume (THRIVE) and balanced turbo field echo (BTFE) images. HR-MRI and CE-MR-C were considered as two datasets, which were independently reviewed by two radiologists with 12 and 2 years' experience respectively. The presence of deep pelvic endometriotic lesions with particular attention to colorectal involvement was recorded. RESULTS: MRI findings correlated with laparoscopy in all cases. Thanks to CE-MR-C images, sensitivity, specificity, PPV, NPV and accuracy for diagnosis of colorectal endometriosis increased from 76%, 96%, 84%, 93% and 91%, to 95%, 97%, 91%, 99% and 97% for the most experienced radiologist and from 62%, 93%, 72%, 89% and 85%, to 86%, 94%, 82%, 96% and 92% for the less experienced radiologist; moreover, the interobserver agreement increased from 0.63 to 0.80 (Cohen's K test). CONCLUSION: CE-MR-C allows easier recognition of colorectal endometriosis and higher interobserver agreement.

Ultrasound of the Uterosacral Ligament, Parametrium, and Paracervix: Disagreement in Terminology between Imaging Anatomy and Modern Gynecologic Surgery.

Ultrasound is an effective tool to detect and characterize lesions of the uterosacral ligament, parametrium, and paracervix. They may be the site of diseases such as endometriosis and the later stages of cervical cancer. Endometriosis and advanced stages of cervical cancer may infiltrate the parametrium and may also involve the ureter, resulting in a more complex surgery. New functional, surgical anatomy requires the complete diagnostic description of retroperitoneal spaces and tissues that contain vessels and nerves. Most endometriosis lesions and cervical cancer spread involve the cervical section of the uterosacral ligament, which is close to tissues, namely the parametrium and paracervix, which contain vessels and important nerves and nerve anastomoses of the inferior hypogastric plexus. Efferent fibers of the plexus travel to the rectum, uterus, rectovaginal ligament, deep vesicouterine ligament, and bladder. These efferent fibers are essential for bladder and rectal functionality so tailored nerve-sparing surgery became a standard approach for treating deep infiltrating endometriosis and cervical cancer. An accurate diagnosis by ultrasound has significant clinical impact and is important for appropriate treatment. In this article, we try to establish a common terminology between imaging diagnostic and modern surgical anatomy.

Magnetic resonance imaging for deep infiltrating endometriosis: current concepts, imaging technique and key findings.

Endometriosis is an estrogen-dependent chronic disease affecting about 10% of reproductive-age women with symptoms like pelvic pain and infertility. Pathologically, it is defined by the presence of endometrial tissue outside the uterine cavity responsible for a chronic inflammatory process. For decades the diagnosis of endometriosis was based on surgical exploration and biopsy of pelvic lesions. However, laparoscopy is not a risk-free procedure with possible false negative diagnosis due to an underestimate of retroperitoneal structures such as ureters and nerves. For these reasons nowadays, the diagnosis of endometriosis is based on a noninvasive approach where clinical history, response to therapy and imaging play a fundamental role. Trans-vaginal ultrasound and magnetic resonance imaging are suitable for recognizing most of endometriotic lesions; nevertheless, their accuracy is strictly determined by operators' experience and imaging technique. This review paper aims to make radiologists aware of the diagnostic possibilities of pelvic MRI and familial with the MR acquisition protocols and image interpretation for women with endometriosis.

The Multifaceted COVID-19: CT Aspects of Its Atypical Pulmonary and Abdominal Manifestations and Complications in Adults and Children. A Pictorial Review.

Our daily experience in a COVID hospital has allowed us to learn about this disease in many of its changing and unusual aspects. Some of these uncommon manifestations, however, appeared more frequently than others, giving shape to a multifaceted COVID-19 disease. This pictorial review has the aim to describe the radiological aspects of atypical presentations and of some complications of COVID-19 disease in adults and children and provide a simple guide for radiologists to become familiar with the multiform aspects of this disease.

The Role of Multiparametric Magnetic Resonance in Volumetric Modulated Arc Radiation Therapy Planning for Prostate Cancer Recurrence After Radical Prostatectomy: A Pilot Study.

BACKGROUND AND PURPOSE: Volumetric modulated arc radiotherapy (RT) has become pivotal in the treatment of prostate cancer recurrence (RPC) to optimize dose distribution and minimize toxicity, thanks to the high-precision delineation of prostate bed contours and organs at risk (OARs) under multiparametric magnetic resonance (mpMRI) guidance. We aimed to assess the role of pre-treatment mpMRI in ensuring target volume coverage and normal tissue sparing. MATERIAL AND METHODS: Patients with post-prostatectomy RPC eligible for salvage RT were prospectively recruited to this pilot study. Image registration between planning CT scan and T2w pre-treatment mpMRI was performed. Two sets of volumes were outlined, and DWI images/ADC maps were used to facilitate precise gross tumor volume (GTV) delineation on morphological MRI scans. Two rival plans (mpMRI-based or not) were drawn up. RESULTS: Ten patients with evidence of RPC after prostatectomy were eligible. Preliminary data showed lower mpMRI-based clinical target volumes than CT-based RT planning (p = 0.0003): median volume difference 17.5 cm3. There were no differences in the boost volume coverage nor the dose delivered to the femoral heads and penile bulb, but median rectal and bladder V70Gy was 4% less (p = 0.005 and p = 0.210, respectively) for mpMRI-based segmentation. CONCLUSIONS: mpMRI provides high-precision target delineation and improves the accuracy of RT planning for post-prostatectomy RPC, ensures better volume coverage with better OARs sparing and allows non-homogeneous dose distribution, with an aggressive dose escalation to the GTV. Randomized phase III trials and wider datasets are needed to fully assess the role of mpMRI in optimizing therapeutic strategies.

Characterization of endometrial growth in proliferative and early luteal phase in IVF cycles.

Human endometrium has a definite role in implantation, although knowledge about its modifications in the course of IVF cycles is still limited. This study was performed to characterize endometrial growth throughout stimulation treatment in women undergoing IVF cycles, regardless of clinical outcomes. Endometrial growth was longitudinally evaluated by ultrasonography in the first induced ovarian stimulation cycle (717 patients). Acceleration and length of significant growth were used to assess the slope of the growth curve mathematically. Endometrial growth showed a parabolic trend and final thickness was significantly affected by age (P < 0.01). Endometria that tended to overgrowth had a more rapid and longer growth during the whole phase. A similar stimulation treatment was repeated within 6 months of the first one and a second evaluation was carried out to verify whether similar growth occurred. Similar growth was observed in 76% of the patients, with an absolute difference between the two cycles of <4 mm in 84% of cases. The endometrium seems to have an individual intrinsic potential that can be expressed regardless of the stimulation protocol. This supports the hypothesis that individual factors (intrinsic properties of the endometrium) significantly affect endometrial growth.

Apoptosis in normal ovaries of women with and without endometriosis.

The aim of this study was to evaluate the factors predisposing to implants of endometriotic lesions in normal ovarian cortexes of women with and without endometriosis by assessing the expression of pro-apoptotic and anti-apoptotic factors and follicular density. Ovarian biopsies were performed during laparoscopy in 18 patients with endometrioma and in 10 healthy women. Detection of apoptosis was performed with terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling assay. p53 and BCL2 proteins were assessed by immunohistochemistry. Quantitative real-time polymerase chain reaction was performed to evaluate BAX , BAK , BCL2 , BCL-XL , survivin and beta-actin ( ACTB ) expression. The p53 protein was positive in a significantly higher number of secondary follicles, whereas the B-cell chronic lymphocytic leukaemia/lymphoma 2 (BCL2) protein was positive in all follicles in unaffected tissue of endometriotic women, compared with the controls. Overexpression of the BCL2 and survivin genes and a decreased BAX and BAK gene expression were observed in the endometriotic group although only the difference in survivin expression was significant (P = 0.016). The BCL2 / BAX ratio showed an increased value in the ovarian cortex in controls compared with endometriosis patients. In conclusion, the reduction of apoptosis in unaffected tissue in women with endometriosis suggests that they may be predisposed to develop endometriosis.

Adipose tissue, metabolic syndrome and polycystic ovary syndrome: from pathophysiology to treatment.

In the last few years, polycystic ovary syndrome (PCOS) has deserved major attention because it is linked to the same cluster of events that promote the metabolic syndrome. This review will point out the relationships between fat excess, insulin resistance and the metabolic syndrome. Adipocytes are actually considered as endocrine cells that synthesize and release molecules (adipokines) that play an endocrine/paracrine role, such as adiponectin, atrial natriuretic peptide, leptin, resistin, tumour necrosis factor alpha (TNFalpha). Metabolic syndrome is a chronic low-grade inflammatory condition in which adipokines play a major role. Isolated adipocytes from women with PCOS express higher mRNA concentrations of some adipokines involved in cardiovascular risk and insulin resistance. However, environmental factors and lifestyle play a major role in determining the appearance of the phenotypes of PCOS. In morbid obese women with PCOS, bariatric surgery decreases bodyweight and fat excess and reverses hyperandrogenism and sterility. In lean or overweight women with PCOS, changes in lifestyle in combination with drugs reducing visceral fat and insulin resistance reverse the symptoms and signs of PCOS. Promising treatments for PCOS seem to be insulin sensitizers such as metformin and glitazones.

Follicular growth and oocyte maturation in GnRH agonist and antagonist protocols for in vitro fertilisation and embryo transfer.

BACKGROUND: The aim of this study was to evaluate the response to treatment in a group of patients undergoing IVF and randomised to receive GnRH-antagonist or the GnRH-agonist. The endpoints were the pattern of follicular growth, the maturity of the oocytes collected, the embryo quality and the pregnancy outcome. METHODS: A total of 136 patients undergoing IVF were included. Sixty-seven patients were allocated to the GnRH antagonist and 69 patients to the GnRH agonist. GnRH antagonist was administered when the leading follicle reached a diameter of 12-14 mm. GnRH agonist was administered in a long luteal protocol. RESULTS: The mean numbers of oocytes retrieved and mature oocytes were significantly higher in the agonist than in the antagonist group (p < 0.02 and p < 0.01, respectively). Embryo quality, implantation rate, clinical pregnancy rates, ongoing pregnancy rate and miscarriage rate were similar in both groups. CONCLUSIONS: Better follicular growth and oocyte maturation are achieved with GnRH agonist treatment. However, both regimens seem to have similar efficacy in terms of implantation and pregnancy rates. Further studies clarifying the effect of the GnRH antagonist on ovarian function are needed, as well as a clear definition of the best period of the follicular phase for the GnRH antagonist administration.

Intrauterine insemination with recombinant or urinary human chorionic gonadotropin: A prospective randomized trial.

AIM: Our aim was to compare the efficacy and safety of recombinant and urinary human chorionic gonadotropin (rhCG and uhCG, respectively) for the induction of follicle maturation in women undergoing intrauterine insemination (IUI). METHODS: Patients were randomized to receive rhCG or uhCG. IUI was carried out 24 h (day 1) and 48 h (day 2) after hCG administration, except for all cases in which ovulation occurred after 24 h. RESULTS: The two treatments were comparable in terms of progesterone levels on day 7 and day 12. Pregnancy rates were comparable between the treatment groups. Of the 64 women who received rhCG, 29.7% became pregnant; there were 16.7% clinical pregnancies and 3.1% biochemical pregnancies per started cycle, and an ongoing pregnancy rate of 93.7% was reported. Of the 61 patients who received uhCG, 24.6% became pregnant; there were 15.9% clinical pregnancies and 1.1% biochemical pregnancies per started cycle, and ongoing pregnancy rate was 92.9%. No adverse effects were noted in either group. CONCLUSION: The recombinant products can be effectively used instead of urinary products; moreover, apart from the equivalent efficacy in ovulation induction and safety described in this study, it is necessary to consider the advantages provided by the recombinant form.

Office hysteroscopy in an in vitro fertilization program.

OBJECTIVE: In the present paper we evaluate the incidence of intrauterine pathologies in a population undergoing in vitro fertilization (IVF) treatment. Moreover, we compare the IVF outcome between patients with normal and abnormal uterine findings to determine if office hysteroscopy (OH) is of any clinical significance. METHODS: The hysteroscopic findings in 866 consecutive patients were analyzed. The study group included 555 patients at the first IVF attempt and 311 patients with two or more failed IVF cycles. RESULTS: All hysteroscopic parameters were considered normal in 514 cases (59.4%); in 352 cases (40.6%) various pathological conditions were found. Patients were divided into two groups according to the hysteroscopic findings. The implantation and pregnancy rates were similar between the groups. Comparing the clinical outcomes in patients with repeated IVF failure who had hysteroscopy with no pathology and with pathology, we did not find any statistical differences. CONCLUSIONS: This study suggests that hysteroscopy as a routine infertility examination should be performed in all patients, owing to the elevated incidence of hysteroscopic pathological findings (59.4%); hysteroscopy also seems to be the best way to repair the uterine cavity when pathological conditions are present. However, performing OH before IVF-embryo transfer is of no significant value in improving pregnancy outcomes.

Performance of different ovarian reserve markers for predicting the numbers of oocytes retrieved and mature oocytes.

OBJECTIVE: To assess the performance of different ovarian reserve tests for predicting the total numbers of oocytes retrieved and mature oocytes. METHODS: A retrospective study was performed on 71 women undergoing their first IVF/intracytoplasmic sperm injection treatment. Basal ovarian reserve screening was performed on days 2-3 of a spontaneous cycle. Patients were down-regulated with the GnRH agonist, whereas ovarian stimulation was carried out with recombinant FSH, starting from day 2 to 3 of the cycle. The main outcome measures were the numbers of oocytes retrieved and mature oocytes. RESULTS: The total number of oocytes was positively correlated with AFC (p<0.0001) and E(2) levels post-GnRH (p<0.004), whereas there was an inverse correlation with age (p<0.0001). The number of mature oocytes also correlated with AFC (p<0.008) and E(2) levels post-GnRH (p<0.009), and inversely with age (p<0.0004). Univariate linear regression of square root of number of oocytes (SQNO) shows that acceptable predictors of number oocytes, based on model significance and R(2) are AFC (R(2)=0.215), age (R(2)=0.24) and E(2) variation (R(2)=0.09). The following model is proposed to predict the number of mature oocytes: ln(MO)=ln(NO)-2.09+0.028 AGE+0.03 BMI. CONCLUSION(S): The number of antral follicles and patient age appear to be good markers of ovarian response in IVF treatments. Additional information is provided by stimulated E(2) levels.