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Gersak MM, Badea R, Lenghel LM, Vasilescu D, Botar-Jid C, Dudea SM. Influence of Food Intake on 2-D Shear Wave Elastography Assessment of Liver Stiffness in Healthy Subjects. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:1295-1302. [PMID: 26947447 DOI: 10.1016/j.ultrasmedbio.2016.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/22/2015] [Accepted: 01/05/2016] [Indexed: 06/05/2023]
Abstract
Transient elastography and Acoustic Radiation Force Impulse imaging are useful non-invasive methods for liver stiffness estimation, although both are influenced by food intake. The aim of the work described here was to identify liver stiffness variation after a standardized meal using 2-D shear wave elastography. Liver stiffness was estimated in 31 apparently healthy subjects, under fasting conditions and after a standardized meal (20, 40, 60, 80, 100 and 120 min after food intake). In most of the cases, liver stiffness values increased between 20 and 40 min after the meal (p < 0.05) and then significantly decreased between 60 and 80 min (p < 0.05). At 120 min after food intake, liver stiffness values were significantly lower compared with liver stiffness values under fasting conditions (p < 0.05). Gender, but not body mass index, had an important role in liver stiffness variation after food intake (p < 0.01). In conclusion, to avoid the influence of food intake on liver stiffness estimation, 2-D shear wave elastography should be performed only under fasting conditions.
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Affiliation(s)
- Mariana M Gersak
- Department of Radiology, Emergency University County Hospital Cluj, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Radu Badea
- Department of Imaging and Radiology, Ultrasound Imaging Laboratory, Octavian Fodor Regional Institute of Gastroenterology and Hepatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lavinia M Lenghel
- Department of Radiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Dan Vasilescu
- Department of Radiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carolina Botar-Jid
- Department of Radiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Sorin M Dudea
- Department of Radiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Suh CH, Choi YJ, Baek JH, Lee JH. The diagnostic performance of shear wave elastography for malignant cervical lymph nodes: A systematic review and meta-analysis. Eur Radiol 2016; 27:222-230. [DOI: 10.1007/s00330-016-4378-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/18/2016] [Indexed: 01/24/2023]
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Feng JC, Li J, Wu XW, Peng XY. Diagnostic Accuracy of SuperSonic Shear Imaging for Staging of Liver Fibrosis: A Meta-analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:329-339. [PMID: 26795041 DOI: 10.7863/ultra.15.03032] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the performance of SuperSonic shear imaging (SuperSonic Imagine SA, Aix-en-Provence, France) for diagnosis of liver fibrosis. METHODS Literature databases were searched to identify relevant studies from inception to February 28, 2015. Sensitivity, specificity, and other information were extracted from the studies. Pooled data were calculated by a bivariate mixed-effects binary regression model. Subgroup and sensitivity analyses were performed. Publication bias was tested by funnel plots. RESULTS Twelve studies were included in this meta-analysis and reported on 1635 patients. The pooled sensitivity and specificity were 0.78 (95% confidence interval [CI], 0.69-0.85) and 0.95 (95% CI, 0.75-0.99), respectively, for fibrosis stages F≥1, 0.84 (95% CI, 0.81-0.86) and 0.81 (95% CI, 0.74-0.87) for F≥2, 0.89 (95% CI, 0.85-0.93) and 0.84 (95% CI, 0.77-0.89) for F≥3, and 0.88 (95% CI, 0.82-0.91) and 0.86 (95% CI, 0.81-0.90) for F=4. The areas under the summary receiver operating characteristic curves were 0.87 (95% CI, 0.84-0.90) for F≥1, 0.85 (95% CI, 0.81-0.88) for F≥2, 0.93 (95% CI, 0.91-0.95) for F≥3, and 0.93 (95% CI, 0.90-0.95) for F=4. No significant publication bias was found. CONCLUSIONS SuperSonic shear imaging could be used for staging of liver fibrosis. Especially, it has high diagnostic accuracy for severe fibrosis and cirrhosis.
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Affiliation(s)
- Jin-Chun Feng
- Shihezi University School of Medicine, Shihezi, China (J.-C.F.); and Departments of Ultrasound (J.L.) and Hepatobiliary Surgery (X.-W.W., X.-Y.P.), First Affiliated Hospital of the School Medicine, Shihezi University, Shihezi, China
| | - Jun Li
- Shihezi University School of Medicine, Shihezi, China (J.-C.F.); and Departments of Ultrasound (J.L.) and Hepatobiliary Surgery (X.-W.W., X.-Y.P.), First Affiliated Hospital of the School Medicine, Shihezi University, Shihezi, China
| | - Xiang-Wei Wu
- Shihezi University School of Medicine, Shihezi, China (J.-C.F.); and Departments of Ultrasound (J.L.) and Hepatobiliary Surgery (X.-W.W., X.-Y.P.), First Affiliated Hospital of the School Medicine, Shihezi University, Shihezi, China
| | - Xin-Yu Peng
- Shihezi University School of Medicine, Shihezi, China (J.-C.F.); and Departments of Ultrasound (J.L.) and Hepatobiliary Surgery (X.-W.W., X.-Y.P.), First Affiliated Hospital of the School Medicine, Shihezi University, Shihezi, China.
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Ríos-Díaz J, Martínez-Payá JJ, del Baño-Aledo ME, de Groot-Ferrando A, Botía-Castillo P, Fernández-Rodríguez D. Sonoelastography of Plantar Fascia: Reproducibility and Pattern Description in Healthy Subjects and Symptomatic Subjects. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2605-2613. [PMID: 26164287 DOI: 10.1016/j.ultrasmedbio.2015.05.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/28/2015] [Accepted: 05/29/2015] [Indexed: 06/04/2023]
Abstract
The purpose of the work reported here was to describe the sonoelastographic appearance of the plantar fascia of healthy volunteers and patients with fasciitis. Twenty-three healthy subjects and 21 patients with plantar fasciitis were examined using B-mode and real-time sonoelastography (RTSR) scanning. B-Mode examination included fascia thickness and echotexture. Echogenicity and echovariation of the color histogram were analyzed. Fasciae were classified into type 1, blue (more elastic); type 2, blue/green (intermediate); or type 3, green (less elastic). RTSE revealed 72.7% of fasciae as type 2, with no significant association with fasciitis (χ(2) = 3.6, df = 2, p = 0.17). Quantitative analysis of the color histogram revealed a significantly greater intensity of green (mean = 77.8, 95% confidence interval [CI] = 71.9-83.6) and blue (mean = 74.2, 95% CI = 69.7-78.8) in healthy subjects. Echovariation of the color red was 33.4% higher in the fasciitis group than in the healthy group (95% CI = 16.7-50.1). Sonoelastography with quantitative analysis of echovariation can be a useful tool for evaluation of plantar fascia pathology.
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Affiliation(s)
- José Ríos-Díaz
- Health Sciences Department, Universidad Católica San Antonio, Campus de los Jerónimos s/n 30107 Guadalupe, Murcia, Spain
| | - Jacinto J Martínez-Payá
- Health Sciences Department, Universidad Católica San Antonio, Campus de los Jerónimos s/n 30107 Guadalupe, Murcia, Spain
| | - María Elena del Baño-Aledo
- Health Sciences Department, Universidad Católica San Antonio, Campus de los Jerónimos s/n 30107 Guadalupe, Murcia, Spain.
| | - Ana de Groot-Ferrando
- Health Sciences Department, Universidad Católica San Antonio, Campus de los Jerónimos s/n 30107 Guadalupe, Murcia, Spain
| | - Paloma Botía-Castillo
- Health Sciences Department, Universidad Católica San Antonio, Campus de los Jerónimos s/n 30107 Guadalupe, Murcia, Spain
| | - David Fernández-Rodríguez
- Health Sciences Department, Universidad Católica San Antonio, Campus de los Jerónimos s/n 30107 Guadalupe, Murcia, Spain
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Woo H, Lee JY, Yoon JH, Kim W, Cho B, Choi BI. Comparison of the Reliability of Acoustic Radiation Force Impulse Imaging and Supersonic Shear Imaging in Measurement of Liver Stiffness. Radiology 2015; 277:881-6. [PMID: 26147680 DOI: 10.1148/radiol.2015141975] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To compare the reliability of acoustic radiation force impulse (ARFI) imaging and supersonic shear imaging (SSI) in measurement of liver stiffness. MATERIALS AND METHODS This study was approved by the institutional review board, and written informed consent was obtained for all patients. Seventy-nine patients (25 healthy patients, 26 with Child-Pugh class A, and 28 with Child-Pugh class B or C) were enrolled and analyzed from April 2012 to April 2013. In each patient, three abdominal radiologists performed nine measurements of hepatic shear-wave speed with both ARFI imaging and SSI on the same day. Four weeks later, a second session was performed with the same protocol. Interobserver and intraobserver agreements were calculated by using intraclass correlation coefficients. Technical failures and measurement time were evaluated. RESULTS There were four technical failures in the SSI group and one in the ARFI group (P = .375). The overall interobserver agreement of ARFI imaging was significantly higher than that of SSI (0.941 vs 0.828, P < .001). The overall intraobserver agreement of ARFI imaging was significantly higher than that of SSI (0.915 vs 0.829, P < .001). The overall shear-wave speed measured with SSI was higher than that measured with ARFI imaging (2.04 m/sec ± 0.88 vs 1.80 m/sec ± 0.81, P < .001). The measurement time of SSI was longer than that of ARFI imaging (310.8 seconds ± 88.5 vs 84.5 seconds ± 15.4, P < .001). CONCLUSION ARFI imaging was more reliable than SSI in measurement of liver stiffness. The hepatic shear-wave speed measured with SSI was higher than that measured with ARFI imaging, which means that the shear-wave speeds measured with ARFI imaging and SSI cannot be used interchangeably.
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Affiliation(s)
- Hyunsik Woo
- From the Departments of Radiology (H.W.) and Internal Medicine (W.K.), SMG-SNU Boramae Medical Center, Seoul, Korea; and Departments of Radiology (J.Y.L., J.H.Y., B.I.C.) and Family Medicine (B.C.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
| | - Jae Young Lee
- From the Departments of Radiology (H.W.) and Internal Medicine (W.K.), SMG-SNU Boramae Medical Center, Seoul, Korea; and Departments of Radiology (J.Y.L., J.H.Y., B.I.C.) and Family Medicine (B.C.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
| | - Jeong Hee Yoon
- From the Departments of Radiology (H.W.) and Internal Medicine (W.K.), SMG-SNU Boramae Medical Center, Seoul, Korea; and Departments of Radiology (J.Y.L., J.H.Y., B.I.C.) and Family Medicine (B.C.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
| | - Won Kim
- From the Departments of Radiology (H.W.) and Internal Medicine (W.K.), SMG-SNU Boramae Medical Center, Seoul, Korea; and Departments of Radiology (J.Y.L., J.H.Y., B.I.C.) and Family Medicine (B.C.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
| | - Belong Cho
- From the Departments of Radiology (H.W.) and Internal Medicine (W.K.), SMG-SNU Boramae Medical Center, Seoul, Korea; and Departments of Radiology (J.Y.L., J.H.Y., B.I.C.) and Family Medicine (B.C.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
| | - Byung Ihn Choi
- From the Departments of Radiology (H.W.) and Internal Medicine (W.K.), SMG-SNU Boramae Medical Center, Seoul, Korea; and Departments of Radiology (J.Y.L., J.H.Y., B.I.C.) and Family Medicine (B.C.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea
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Procopet B, Berzigotti A, Abraldes JG, Turon F, Hernandez-Gea V, García-Pagán JC, Bosch J. Real-time shear-wave elastography: applicability, reliability and accuracy for clinically significant portal hypertension. J Hepatol 2015; 62:1068-75. [PMID: 25514554 DOI: 10.1016/j.jhep.2014.12.007] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/03/2014] [Accepted: 12/05/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Real-time shear wave elastography (RT-SWE) might be useful to assess the severity of portal hypertension; reliability criteria for measurement are needed. METHODS We prospectively included 88 consecutive patients undergoing hepatic venous pressure gradient measurement (HVPG, reference standard) for portal hypertension. Liver stiffness (LS) was measured by RT-SWE and by transient elastography (TE). Spleen stiffness (SS) was measured by RT-SWE. Reliability criteria for RT-SWE were searched, and the accuracy of these techniques to identify HVPG ⩾10mmHg (clinically significant portal hypertension, CSPH) was tested and internally validated by bootstrapping analysis. RESULTS LS and SS by RT-SWE were feasible respectively in 87 (99%) and 58 (66%) patients. Both correlated with HVPG (LS: R=0.611, p<0.0001 and SS: R=0.514, p<0.0001). LS performed well for diagnosing CSPH (optimism corrected AUROC=0.858). Reliability of measurements was influenced by standard deviation (SD)/median ratio and depth. SD/median ⩽0.10 and depth of measurement <5.6cm were associated to 96.3% well classified for CSPH, while when one or none of the criteria were fulfilled the rates were 76.4% and 44.4%, respectively. Measurements fulfilling at least one criterion were considered acceptable; in these patients, RT-SWE performance to detect CSPH was excellent (AUROC=0.939; 95% CI: 0.865-1.000; p<0.0001; best cut-off: 15.4kPa). LS by RT-SWE and by TE were strongly correlated (R=0.795, p<0.0001) and performed similarly both in "per protocol" and in "intention-to-diagnose" analysis after applying reliability criteria. CONCLUSIONS LS by RT-SWE is an accurate method to diagnose CSPH if reliability criteria (SD/median ⩽0.10 and/or depth <5.6cm) are fulfilled.
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Affiliation(s)
- Bogdan Procopet
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
| | - Annalisa Berzigotti
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Spain.
| | - Juan G Abraldes
- Cirrhosis Care Clinic (CCC), Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Fanny Turon
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
| | - Virginia Hernandez-Gea
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Spain
| | - Juan Carlos García-Pagán
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Spain
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Spain
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Ding H, Ma JJ, Wang WP, Zeng WJ, Jiang T, Huang BJ, Chen SY. Assessment of liver fibrosis: the relationship between point shear wave elastography and quantitative histological analysis. J Gastroenterol Hepatol 2015; 30:553-8. [PMID: 25250854 DOI: 10.1111/jgh.12789] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Traditional pathological scoring systems for liver fibrosis progression are predominantly based on the description of architectural changes with no consideration of the amount of collagen fiber deposition. Our purpose was to explore a true histological standard in accordance with the liver stiffness measured by point shear wave elastography (PSWE) in patients with chronic hepatitis B. METHODS A total of 78 patients with liver neoplasms underwent liver stiffness measurements with PSWE as well as biochemical investigations within 3 days before partial hepatectomy. One tissue section of the liver specimens was stained with HE trichrome and evaluated traditionally with the Scheuer scoring system. The other tissue section was stained with picroSirius red and was evaluated according to the semiquantitative Chevallier et al. scoring system. In addition, this second tissue section was evaluated for the collagen proportionate area (CPA) with computer-assisted digital image analysis. The reproducibility of PSWE technology was explored through the intra-class correlation coefficient of a reliability analysis. RESULTS The PSWE technology revealed good reproducibility in liver stiffness measurements, and the PSWE values increased with the pathological severity of liver fibrosis on both the Scheuer scoring system and the semiquantitative Chevallier et al. scoring system. PSWE values exhibited more reasonable relationships with CPA (r = 0.628, P = 0.00 < 0.05) than with the Scheuer scoring system (r = 0.473, P = 0.00 < 0.05) or the Chevallier et al. semiquantitative scoring system (r = 0.487, P = 0.00 < 0.05). CONCLUSION CPA is a better pathological parameter than traditional semiquantitative scoring systems in accordance with liver stiffness measured by PSWE technology.
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Affiliation(s)
- Hong Ding
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
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Cantisani V, Grazhdani H, Drakonaki E, D'Andrea V, Di Segni M, Kaleshi E, Calliada F, Catalano C, Redler A, Brunese L, Drudi FM, Fumarola A, Carbotta G, Frattaroli F, Di Leo N, Ciccariello M, Caratozzolo M, D'Ambrosio F. Strain US Elastography for the Characterization of Thyroid Nodules: Advantages and Limitation. Int J Endocrinol 2015; 2015:908575. [PMID: 25954310 PMCID: PMC4411438 DOI: 10.1155/2015/908575] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 03/19/2015] [Indexed: 01/02/2023] Open
Abstract
Thyroid nodules, with their high prevalence in the general population, represent a diagnostic challenge for clinicians. Ultrasound (US), although absolutely reliable in detecting thyroid nodules, is still not accurate enough to differentiate them into benign and malignant. A promising novel modality, US elastography, has been introduced in order to further increase US accuracy. The purpose of this review article is to assess the thyroid application of US strain elastography, also known as real-time elastography or quasistatic elastography. We provide a presentation of the technique, and of up-to-date literature, analyzing the most prominent results reported for thyroid nodules differentiation. The practical advantages and limitations of strain elastography are extensively discussed herein.
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Affiliation(s)
- Vito Cantisani
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
- *Vito Cantisani:
| | - Hektor Grazhdani
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Elena Drakonaki
- Venizelio Regional General Hospital of Heraklion, Leoforos Knosou, 714 09 Iraklio, Greece
| | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Mattia Di Segni
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Erton Kaleshi
- University of Tirana, Rruga Arben Broci, Tirana, Albania
| | - Fabrizio Calliada
- University Hospital of Pavia, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Carlo Catalano
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Adriano Redler
- Department of Surgical Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Luca Brunese
- Department of Medicine and Health Sciences, University of Molise, Contrada Tappino, 86100 Campobasso, Italy
| | - Francesco Maria Drudi
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Angela Fumarola
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Giovanni Carbotta
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Fabrizio Frattaroli
- Department of Surgical Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161 Rome, Italy
| | - Nicola Di Leo
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Mauro Ciccariello
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Marcello Caratozzolo
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Ferdinando D'Ambrosio
- Department of Radiology, Anatomopathology and Oncology, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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