[From evidence to care sustainability: risk management by contrast agent in cancer patient. Experience in an italian teaching hospital]. / Dalle evidenze alla sostenibilità assistenziale: la gestione del rischio da mezzo di contrasto nel paziente oncologico. Esperienza in un centro universitario italiano.

The use of organo-iodinated contrast media (CM) in diagnostics and intervention has increased in the last 10 years. It is necessary to distinguish between the different types of contrast agent, primarily with respect to osmolarity: with low osmolarity the safety profile for the patient is higher. The risk of acute renal injury caused by contrast agent (PC-AKI) is however determined also by risk factors related to the patient. Particularly in main centers, it is advisable to have a standardized program in order to stratify patients with respect to risk, to define prevention strategies and the roles of the specialists involved. The experience described in this work consists in the application of an organizational model relating to CT, with a feasibility study of applying an evidence-based check-list in the clinical routine, as a tool to support clinical decisions (Clinical Decision Support System, CDSS) in the oncology field. A pilot evaluation was carried out on 54 patients belonging to the case series treated in a Teaching Hospital, in a day service regime with a diagnosis of solid tumor. The results of this evaluation led the working group to believe that the CDSS thus structured determines the possibility of overestimating the clinical risk of PC-AKI, and consequently to redefine the evaluation form. Experience has shown that it is not generally easy to immediately identify an algorithm useful for standardizing the management of clinically complex situations, such as PC-AKI prevention. The conduction of pilot evaluations can be a valid instrument of harmonization between the solidity of the references deriving from evidence based medicine and the tangibility of real world data. It is advisable to broaden the application of the CDSS more in a larger number of cases, as well as conduct a pre-post analysis relating to the clinical impact in terms of incidence from PC-AKI.

Thromboembolic complications of COVID-19: the combined effect of a pro-coagulant pattern and an endothelial thrombo-inflammatory syndrome.

Coronavirus disease 2019 (COVID-19) is a newly emerging human infectious disease that has quickly become a worldwide threat to health, mainly causing severe acute respiratory syndrome. In addition to the widely described respiratory syndrome, COVID-19 may cause life-treating complications directly or indirectly related to this infection. Among these, thrombotic complications have emerged as an important issue in patients with COVID-19 infection, particularly in patients in intensive care units. Thrombotic complications due to COVID-19 are likely to occur due to a pro-coagulant pattern encountered in some of these patients or to a progressive endothelial thrombo-inflammatory syndrome causing microvascular disease. In the present authors' experience, from five different hospitals in Italy and the UK, imaging has proved its utility in identifying these COVID-19-related thrombotic complications, with translational clinical relevance. The aim of this review is to illustrate thromboembolic complications directly or indirectly related to COVID-19 disease. Specifically, this review will show complications related to thromboembolism due to a pro-coagulant pattern from those likely related to an endothelial thrombo-inflammatory syndrome.

Colorectal cancer in patients with type 2 diabetes mellitus: a single-center experience.

Type 2 diabetes mellitus (T2DM) is associated with an increased risk of colorectal cancer (CRC). The aim of the study is to evaluate the prevalence of CRC in a cohort of Caucasian patients with T2DM and the association with other variables previously known to be related with increased risk of CRC. We retrospectively evaluated the data of 741 consecutive Caucasian patients with T2DM who underwent colonoscopic screening in our tertiary referral center. A control cohort of 333 patients with thyroid disease was selected to evaluate the difference in the incidence of CRC. At a median follow-up of 132.5 months (range 33.3-175.7), 67 cases of cancer (prevalence 9%) occurred; among these, 14 cases of CRC were reported (prevalence 1.88%) among the diabetic patients, while only two case (one of these was a CRC) (overall prevalence 0.006%, prevalence of CRC 0.003%) occurred in the control group; the difference between the prevalence of CRC was statistically significant (chi-square 4.21, p=0.04). The median duration of T2DM to CRC diagnosis was 168 months (range 12-768). At the univariate analysis, older age (p=0.001, r 0.138) and diabetes duration (p=0.001, r 0.138) were related to higher risk of cancer, while metformin seems to be protective towards cancer (p=0.07, r -0.098). In the subset of patients with CRC, the age (RR = 2.25; 95% CI: 0.30 - 17.31; p less than 0.001), the diabetes duration (RR = 1.93; 95% CI: 0.25 – 14.77; p = 0.001) and the sulphonylureas treatment (RR = 2.33; 95% CI: 0.78 – 7.38; p = 0.007) were independently correlated with CRC. In our study, the prevalence of CRC in the cohort of patients with T2DM was higher compared to that from the National Tumor Register in 2010 (0.5%). Furthermore, we could speculate that sulphonylureas may play a role in CRC carcinogenesis impairing the physiological insulin secretion.

Focal active colitis as a predictor of inflammatory bowel disease: results from a single-center experience.

The term focal active colitis (FAC) is conventionally used to describe the presence of isolated cryptitis, characterized by an inflammatory infiltrate consisting of intraepithelial neutrophils and/or neutrophils invading the lumen of the criptae, with no other microscopic alteration of the colonic mucosa and, in particular, without the presence of signs of chronic inflammation. To date, only four studies, including one conducted in a pediatric population, have been performed to evaluate the clinical significance of this disease. The aim of this retrospective study on prospectively-collected data is to evaluate the clinical implications of the focal active colitis, since there still remains a marked uncertainty regarding this topic and about how often such a diagnosis will presage a diagnosis of inflammatory bowel disease (IBD). Clinical, endoscopic, and pathological data were retrospectively reviewed from 30 patients with focal active colitis, who had no other diagnostic findings on colorectal biopsy and no history of chronic inflammatory bowel disease. The histological findings were correlated with clinical diagnoses. Thirty patients (11 males, 19 females; age 24-80 years, median 56 years) (0.5%) out of 5,600 undergoing colonoscopy between January 2012 and December 2016 presented a definitive diagnosis of FAC. Follow-up ranged from 6 to 60 months (median 24 months). At endoscopy, 19 patients (63%) had mild and non-specific changes, such as mild mucosal erythema, while 11 (37%) had normal findings. Eight patients were documented as having irritable bowel syndrome, while nine cases could be attributed to the effects of drugs, five presented FAC as incidental finding, one a diagnosis of infectious colitis, and seven a diagnosis of IBD (4 with Crohn’s disease). FAC was confirmed to be a more significant predictor of IBD than the previous literature would indicate, even if larger prospective studies, targeted to study this relationship, are needed to understand more clearly its clinical significance.

Renal endometriosis mimicking complicated cysts of kidney: report of two cases.

Endometriosis is a common gynecologic disorder characterized by ectopic endometrial tissue growth outside the uterine cavity. Although usually occurring in pelvic organs, endometrial lesions may involve urinary tract. Renal endometriosis is extremely rare and it has only occasionally been reported in the past. We report two cases of patients with renal cystic lesions, incidentally found at imaging techniques during oncologic follow-up for gastric sarcoma and melanoma, initially misinterpreted as complicated haemorrhagic cysts and then histologically characterized as renal localizations of extragenital endometriosis.

Caecal leiomyoma detected by whole-body MRI in a patient with Hodgkin lymphoma: first case report.

INTRODUCTION: Hodgkin Lymphoma (HL) is one of the most curable malignant diseases. Modern treatments, like the combined radiochemotherapy and stem cell transplantation, have increased the number of malignant disease survivors. However, HL survivors are at risk of long-term effects, including the development of solid tumors. Secondary neoplasms are a major cause of late morbidity and mortality following treatment for HL. CASE REPORT: We report the case of a male patient, treated for HL by chemotherapy, who developed a large leiomyoma of the cecum one year after the treatment. A whole-body Magnetic Resonance (WBMRI) scan performed during the follow-up allowed the detection of this incidental caecal mass that was absent in a Computed Tomography (CT) scan performed immediately after the treatment. After a CT-guided biopsy, the lesion was surgically removed and the diagnosis of caecal leiomyoma was obtained. DISCUSSION: To our knowledge, this is the first case report, according to the scientific literature, of caecal leiomyoma developing after chemotherapy in a HL survivor. Leiomyoma is a rare benign tumor that usually appears as a solitary small mass with a nodular growth and a benign course. CONCLUSION: This case shows that WB-MRI allows detecting relevant incidental findings during the oncologic follow-up, avoiding both radiation exposure and contrast agent administration. Furthermore, leiomyoma should be considered in the differential diagnosis between the caecal masses with high growth rate.

Common and uncommon pitfalls in pancreatic imaging: it is not always cancer.

Despite advances in multimodality imaging of pancreas, there is still overlap between imaging findings of several pancreatic/peripancreatic disease processes. Pancreatic and peripancreatic non-neoplastic entities may mimic primary pancreatic neoplasms on ultrasound, CT, and MRI. On the other hand, primary pancreatic cancer may be overlooked on imaging because of technical and inherent factors. The purpose of this pictorial review is to describe and illustrate pancreatic imaging pitfalls and highlight the basic radiological features for proper differential diagnosis.

Intratumoral haemorrhage causing an unusual clinical presentation of a vestibular schwannoma.

We present a case of an elderly woman with no history of audiological disease with sudden onset of visual and hearing deficits associated with systemic clinical signs. On examination she had impairment of right CNs from V to X. CT and MR imaging demonstrated a cystic vestibular schwannoma with a rare intralesional fluid-fluid level correlated to a recent bleed. We include high quality MR images to show the acute impairment of the cranial nerves next to the tumour after acute bleeding. Our case report includes a voxel-based morphometry (VMB) analysis of the tumour that, as far as we know, has never been done before for such a tumour. VBM analysis was performed to calculate the hypothesized volume changes after the acute bleed which likely resulted in a sudden increase in the overall size of the tumour resulting in atypical clinical signs and symptoms due to the establishment of a mechanical conflict with the adjacent cranial nerves.

Small solid renal masses: characterization by diffusion-weighted MRI at 3 T.

AIM: To describe the appearance of small solid renal lesions (≤3 cm) on diffusion-weighted magnetic resonance imaging (MRI) and to determine whether ADC measurements may help to differentiate benign from malignant small solid renal masses. METHODS AND MATERIALS: Thirty-five patients with 47 small renal masses (23 malignant, 24 benign) who underwent 3 T MRI of the kidney using diffusion-weighted sequences (b values of 0 and 1000 s/mm(2)) were retrospectively evaluated. Qualitative and quantitative analysis of diffusion-weighted images was performed. RESULTS: Most lesions were hyperintense to kidney on high b-value diffusion-weighted images and hypointense on apparent diffusion coefficient (ADC) map. The mean ADC of the lesions was significantly lower than that of kidney (1.22 ± 0.3 versus 1.85 ± 0.12 mm(2)/s; p < 0.005). The mean ADC was significantly different between renal cell carcinomas (1.2 ± 0.01 mm(2)/s), metastases (1.25 ± 0.04 mm(2)/s), angiomyolipoma (1.07 ± 0.3 mm(2)/s) and oncocytomas (1.56 ± 0.08 mm(2)/s; p < 0.05). The mean ADC of clear cell renal cell carcinomas was significantly different from that of non-clear cell renal cell carcinomas (1.38 ± 0.34 versus 0.83 ± 0.34 mm(2)/s; p < 0.005). No significant difference was found between mean ADC of fat containing and minimal fat angiomyolipomas (1.06 ± 0.48 versus 1.11 ± 0.33 mm(2)/s). CONCLUSION: Small solid renal masses are hyperintense on high b value and have different ADC values.

Rationale, design and methods of CTCA-PRORECAD (Computed Tomography Coronary Angiography Prognostic Registry for Coronary Artery Disease): a multicentre and multivendor registry.

PURPOSE: This study was done to assess the prognostic value of computed tomography coronary angiography (CTCA) in a large multicentre population of patients with suspected coronary artery disease (CAD) and, in particular, its incremental value compared with traditional methods for risk stratification. MATERIALS AND METHODS: This is a retrospective observational study that began in January 2003 conducted on patients with suspected CAD assessed with CTCA on the basis of symptoms (chest pain, dyspnoea) and/or abnormal or equivocal stress test and/or a high cardiovascular risk profile. The participating centres will provide data obtained with CTCA performed with 16-slice or higher equipment. Exclusion criteria are renal insufficiency, allergy to iodinated contrast material, pregnancy and previous myocardial infarction or revascularisation (percutaneous coronary intervention and/or coronary artery bypass graft). All patients are stratified by means of clinical assessment and/or data retrieved from a clinical database. Risk factors considered are hypertension, dyslipidaemia, diabetes mellitus, smoking, family history and obesity. Symptoms are classified as absent, typical chest pain, atypical chest pain and dyspnoea. Primary endpoints are death, major adverse cardiovascular events (cardiac death, unstable angina requiring hospitalisation, acute myocardial infarction) and shifting of cardiovascular risk category on the basis of coronary plaque burden. The secondary endpoint is coronary revascularisation. Telephone interviews and/or clinical databases are used for the follow-up. The study will be conducted on a population >1,000 patients. CONCLUSIONS: The information collected from the Prognostic Registry for Coronary Artery Disease (PRORECAD) will provide insight into the prognostic value of CTCA in addition to demographic and clinical features. The results will allow for better use and interpretation of CTCA for prognostic purposes.

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

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

Comparison of iodinated contrast media for the assessment of atherosclerotic plaque attenuation values by CT coronary angiography: observations in an ex vivo model.

OBJECTIVE: To compare the influence of different iodinated contrast media with several dilutions on plaque attenuation in an ex vivo coronary model studied by multislice CT coronary angiography. METHODS: In six ex vivo left anterior descending coronary arteries immersed in oil, CT (slices/collimation 64×0.625 mm, temporal resolution 210 ms, pitch 0.2) was performed after intracoronary injection of a saline solution, and solutions of a dimeric isosmolar contrast medium (Iodixanol 320 mgI ml(-1)) and a monomeric high-iodinated contrast medium (Iomeprol 400 mgI ml(-1)) with dilutions of 1/80 (low concentration), 1/50 (medium concentration), 1/40 (high concentration) and 1/20 (very high concentration). Two radiologists drew regions of interest in the lumen and in calcified and non-calcified plaques for each solution. 29 cross-sections with non-calcified plaques and 32 cross-sections with calcified plaques were evaluated. RESULTS: Both contrast media showed different attenuation values within lumen and plaque (p<0.0001). The correlation between lumen and non-calcified plaque values was good (Iodixanol r=0.793, Iomeprol r=0.647). Clustered medium- and high-concentration solutions showed similar plaque attenuation values, signal-to-noise ratios (SNRs) (non-calcified plaque: medium solution SNR 31.3±15 vs 31.4±20, high solution SNR 39.4±17 vs 37.4±22; calcified plaque: medium solution SNR 305.2±133 vs 298.8±132, high solution SNR 323.9±138 vs 293±123) and derived contrast-to-noise ratios (p>0.05). CONCLUSION: Differently iodinated contrast media have a similar influence on plaque attenuation profiles. ADVANCES IN KNOWLEDGE: Since iodine load affects coronary plaque attenuation linearly, different contrast media may be equally employed for coronary atherosclerotic plaque imaging.

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.

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

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

Incidence of new foci of hepatocellular carcinoma after radiofrequency ablation: role of multidetector CT.

PURPOSE: The authors sought to assess the incidence of new foci of hepatocellular carcinoma (HCC) using multidetector computed tomography (MDCT) in patients treated with radiofrequency ablation (RFA). MATERIALS AND METHODS: Two readers retrospectively reviewed by consensus the follow-up MDCT studies of 125 patients (88 men and 37 women; mean age 68 years) with 141 HCCs (size 1-5.2 cm; mean 2.2 cm) treated with RFA. MDCT follow-up was performed at 1 and 3 months and every 6-12 months thereafter. Reviewers assessed: (1) the presence of new HCC foci in the same liver segment or in a different segment; (2) complete or incomplete tumour ablation; (3) tumour progression. RESULTS: A total of 113 new HCCs (size 0.7-4.8 cm; mean 1.7 cm) were detected in 69/125 (55.2%) patients (mean follow-up 30.38±19.14 months). Of these, 86 (76.1%) new HCCs were multiple (p<0.0001), and 92 (81.4%) occurred in a different segment from that of the treated HCC (p<0.0001). New HCCs were observed in the first 12 months, between 12 and 24 months and after 24 months in 31/69 (44.9%), 24/69 (34.8%) and 14/69 (20.3%) patients, respectively (p=0.175). Mean diseasefree interval was 16.1±16.31 (range 1-52) months. Complete tumour ablation was achieved in 132/141 (93.6%) treated HCCs, and tumour progression occurred in 29/141 (20.6%) cases. CONCLUSIONS: In patients with RFA-treated HCCs, MDCT follow-up revealed a high incidence of new HCCs, even after 1 year of follow-up. The new foci tended to be multiple and located in a liver segment different from that of the previously treated nodules.

Computed tomography coronary angiography in asymptomatic patients.

PURPOSE: This study assessed the accuracy of computed tomography coronary angiography (CT-CA) for detecting significant coronary artery disease (CAD; ≥50% lumen reduction) in intermediate/high-risk asymptomatic patients. MATERIALS AND METHODS: A total of 183 consecutive asymptomatic individuals (92 men; mean age 54±11 years) with more than one major risk factor (obesity, hypertension, diabetes, hypercholesterolaemia, family history, smoking) and an inconclusive or nonfeasible noninvasive stress test result (stress electrocardiography, stress echocardiography, nuclear stress scintigraphy) underwent CT-CA in an outpatient setting. All patients underwent conventional coronary angiography (CAG) within 4 weeks. Data from CT-CA were compared with CAG regarding the presence of significant CAD (≥50% lumen reduction). RESULTS: Mean calcium score was 177±432, mean heart rate during the CT-CA scan was 58±8 bpm and the prevalence (per-patient) of obstructive CAD was 19%. CT-CA showed single-vessel CAD in 9% of patients, two-vessel CAD in 9% and three-vessel CAD in 0%. Per-patient sensitivity, specificity, positive predictive value and negative predictive value of CT-CA were 100% (90-100), 98% (96-99), 97% (85-99), 100% (97-100), respectively. Positive and negative likelihood ratios were 151 and 0, respectively. CONCLUSIONS: CT-CA is an excellent noninvasive imaging modality for excluding significant CAD in intermediate/ high-risk asymptomatic patients with inconclusive or nonfeasible noninvasive stress test.

Prognostic value of Morise clinical score, calcium score and computed tomography coronary angiography in patients with suspected or known coronary artery disease.

PURPOSE: Our aim was to determine the prognostic value of computed tomography coronary angiography (CTCA), coronary artery calcium scoring (CACS) and Morise clinical score in patients with known or suspected coronary artery disease (CAD). MATERIALS AND METHODS: A total of 722 patients (480 men; 62.7±10.9 years) who were referred for further cardiac evaluation underwent CACS and contrast-enhanced CTCA to evaluate the presence and severity of CAD. Of these, 511 (71%) patients were without previous history of CAD. Patients were stratified according to the Morise clinical score (low, intermediate, high), to CACS (0-10, 11-100, 101-400, 401-1,000, >1,000) and to CTCA (absence of CAD, nonsignificant CAD, obstructive CAD). Patients were followed up for the occurrence of major events: cardiac death, nonfatal myocardial infarction, unstable angina and revascularisation. RESULTS: Significant CAD (>50% luminal narrowing) was detected in 260 (36%) patients; nonsignificant CAD (<50% luminal narrowing) in 250 (35%) and absence of CAD in 212 (29%). During a mean follow-up of 20±4 months, 116 events (21 hard) occurred. In patients with normal coronary arteries on CTCA, the major event rate was 0% vs. 1.7% in patients with nonsignificant CAD and 7.3% in patients with significant CAD (p<0.0001). Three hard events (14%) occurred in patients with CACS≤100 and two (9.5%) in patients with intermediate Morise score; one revascularisation was observed in a patient with low Morise score. At multivariate analysis, diabetes, obstructive CAD and CACS >1,000 were significant predictors of events (p<0.05). CONCLUSIONS: An excellent prognosis was noted in patients with a normal CTCA (0% event rate). CACS ≤100 and low-intermediate Morise score did not exclude the possibility of events at follow-up.