Pulmonary congenital cystic disease in adults. Spiral computed tomography findings with pathologic correlation and management

Conventional Radiology Evaluation of Neonatal Intravascular Devices (NIVDs): A Case Series

Our radiology department conducted an assessment of 300 neonatal radiographs in the neonatal intensive care unit over almost two years. The purpose was to evaluate the correct positioning of intravascular venous catheters. Our case series revealed that out of a total of 95 cases with misplaced devices, 59 were umbilical venous catheters and 36 were peripherally inserted central catheters. However, all of the central venous catheters were found to be properly positioned. Misplacements of neonatal intravascular devices were found to occur more frequently than expected. The scientific literature contains several articles highlighting the potential complications associated with misplaced devices. Our goal is to highlight the potential misplacements and associated complications that radiologists may encounter while reviewing conventional radiology imaging. Based on our experience, which primarily involved placing UVCs and PICCs, we discovered that conventional radiology is the most effective method for assessing proper device placement with the lowest possible radiation exposure. Given the high number of neonatal vascular device placement procedures, it is essential for radiologists to maintain a high level of vigilance and stay updated on the latest developments in this field.

When to perform vertebroplasty? A retrospective analysis from a single center and a review of the literature

BACKGROUND AND AIM

To establish an optimal timing for vertebroplasty in order to obtain a clinically important pain reduction and improving quality of live in patients with osteoporotic or traumatic vertebral fractures.

METHODS

This study includes 22 vertebroplasty procedures performed from October 2018 to July 2020 in 21 patients with traumatic or osteoporotic vertebral fractures (19 female, two men; age between 53 and 89 years). All treatments were executed under fluoroscopic guidance using 11 or 13 G needle through transpedicular or costovertebral unilateral approach. Each patient underwent conscious sedation, continuously monitored by an anesthesiologist. Preoperative MRI images, obtained by 3T or 1.5T MRI scanner, always showed bone marrow edema. The VAS scale and Roland Morris disability questionnaire (RMdq) were administered to patients before and after the treatment to evaluate pain and life quality.

RESULTS

7 patients were treated in the first month after the injury, one was treated twice; 8 patients in the second month, 6 in the third. We observed a reduction of: 5.5 points in the vas scale, 10.3 in the RMdq in the first month; 5.6 points vas, 11.6 points RMdq in the second month; 4 points vas and 9.75 points RMdq in the third month.

CONCLUSIONS

This study demostrated that, in our preliminary experience, vertebroplasty has the best outcome if performed at 2 months from injury.

Cervical spine trauma: impact of different imaging classification systems in the clinical decision-making

Background and aim:

Considering the high rate of mortality and permanent disability related to vertebral traumas, an early and detailed diagnosis of the trauma and subsequently an immediate and effective intervention are crucial. Cervical vertebral injury classifications guide treatment choice through a severity grade based on radiological information. The purpose of the present study was to define which imaging classification system could provide the best morphological and clinical-surgical correlations for cervical spine traumas.

Methods:

We retrospectively analyzed patients evaluated for cervical spine trauma at our Institution in the period 2015-2020. Information regarding the morphological examination (using CT and MRI), the neurological evaluation, and the therapeutic management were collected. C3-C7 fractures were classified according to the SLIC and AOSpine criteria; axial lesions were classified according to the modified AOSpine for the C1-C2 compartment and through the Roy-Camille and the Anderson D’Alonzo system for the odontoid process of the axis.

Results:

29 patients were included in the final study population. Nine patients with axial spine trauma and 21 with subaxial cervical spine trauma. A conservative approach was applied in 16 patients while nine patients underwent neurosurgery. Considering the therapeutical indications provided by the SLIC system, a 76.9% accordance was found for patients with a <4 score, while a 100% concordance was calculated for patients with a >4 score undergoing neurosurgery. Regarding the AOSspine classification, a 28.6% concordance was observed for patients classified group B being treated with a posterior neurosurgical approach, while for patients belonging to subgroup C, considered for anterior neurosurgical approach, a 66.7% accordance was calculated.

Conclusions:

The study demonstrated a better morphological correlation for the AOSpine classification in subaxial trauma and the AOSpine and Anderson D’Alonzo in axial trauma. The therapeutic indication found a better correlation in the SLIC classification for subaxial trauma and the Anderson D’Alonzo for axial ones. (www.actabiomedica.it)

Basics in Magnetic Resonance guided Focused Ultrasound: technical basis and clinical application. A brief overview

First applications of high focused ultrasound as intracranial ablative therapy were firstly described in early 50’. Since then, the technological innovations have shown an increasingly safe and effective face of this technique. And in the last few years, Magnetic Resonance (MR) guided Focused Ultrasound (gFUS) has become a valid minimally invasive technique in the treatment of several diseases, from bone tumors to symptomatic uterine fibroids or essential tremors. MR guidance, through the tomographic view, offers the advantage of an accurate target detection and treatment planning. Moreover, real-time monitoring sequences allow to avoid non-target ablation. An adequate knowledge of FUS is essential to understand its clinical effectiveness. Therefore, this brief review aims to debate the physical characteristics of US and the main fields of clinical application.

Diagnostic performance of DIXON sequences on low-field scanner for the evaluation of knee joint pathology

BACKGROUND AND AIM

Recently, there has been a growing interest in the use of Dixon sequence for knee MRI in order to save time spent on the scanner, and improving diagnostic utility. Our purpose was to compare the diagnostic performance of Dixon sequence on low-field MRI with the proton-density sequence on high-field MRI.

METHODS

This prospective study included 40 patients who underwent 0.25T knee MRI, using the routine protocol with the addition of a sagittal 4-point Dixon sequence (SPED), and an additional sequence on 1.5T scanner, consisting in a fat-suppressed proton-density fast-spin-echo (FS PD-FSE). Two radiologists independently examined the images, evaluating the anatomic identification score and diagnostic performances of the two sequences. Interreader agreement was evaluated using an intraclass correlation coefficient (ICC).

RESULTS

Final population counted 34 patients (36 knee MR images) with a mean age of 52.9 years (range, 18-75 years). Interreader agreement was very high except for cartilage injuries at medial femoral condyle and medial tibial plateau (ICC SPED: 0.757, ICC FS PD-FSE: 0.746), even if not statistically significant. There were no significant differences in mean signal-to-noise ratio (SNR), artifacts presence and diagnostic confidence between SPED and PD-FS sequence.

CONCLUSIONS

Dixon sequences on low-field scanner have a comparable diagnostic accuracy to PD-FS sequence obtained on a high field scanner for knee MR imaging. (www.actabiomedica.it).

The role of interventional radiology in hepatic and renal hemorrhage embolization: single center experience and literature review

Background and aim:

Intraabdominal hemorrhage secondary to liver and kidney injury is a major cause of morbidity and mortality. Endovascular arterial embolization is an established interventional radiology technique used to treat active bleeding, and its role in managing abdominal hemorrhages is growing, given the increasing trend for conservative treatment. Our study aims to retrospectively evaluate the technical and clinical results and the possible complications of arterial embolization procedures performed in emergency, in post-traumatic, iatrogenic, and pathological hepatic and renal bleedings.

Methods:

We performed a ten-year, single-center retrospective survey (from January 2010 to December 2019) of all patients treated in emergency by intra-arterial embolization of liver and kidney bleeding. Preliminary CT angiography studies were evaluated, as well as the angiographic findings. Materials used, procedural data, and clinical outcomes, including complications, were recorded.

Results:

The diagnostic angiography showed a single source of bleeding in 20 cases (66.7%), two bleeding vessels in 4 cases (13.3%), and multiple hemorrhagic sources in 6 cases (20%). All bleeding sources were successfully embolized; in 12 patients (40%), complete embolization was achieved with coils and 18 patients (60%) with hemostatic sponges. In one case, a second embolization procedure was performed for the persistence of hemodynamic instability. No major post-procedural complications were recorded. The mean procedure duration was 65.1 minutes.

Conclusions:

Based on our experience and literature data, the treatment of endovascular embolization in acute abdominal bleeding of hepatic and renal origin represents the treatment of choice, as it can provide complete therapeutic success in hemodynamically stable patients. (www.actabiomedica.it)

The texture analysis as a predictive method in the assessment of the cytological specimen of CT-guided FNAC of the lung cancer

The lung cancer is the principle cause of the worldwide deaths and its prognosis is poor with a 5-year overall survival rate. Computed tomography (CT) gives many information about the prognosis, but the problem is the subject interpretation of the findings. Thanks to the computer-aided diagnosis/detection (CAD), it is possible to reduce the second opinion. "Radiomics" is an extension of CAD and overlaps the quantitative imaging data of the CT texture analysis (CTTA) with the clinical information, increasing the power and precision of the decision going through the personalized medicine. The aim of this study is to describe the role of the radiomics in the characterization of the pulmonary nodule. For this study, we retrospectively analyzed the images of the 87 NSCLC patients with a waiver of informed consent from the Institutional Review Board (IRB) at the Campania University "Luigi Vanvitelli" of Naples. All tumors were semiautomatically segmented by a radiologist with 10 years of experience using three diameters (AW Server 3.2). The examinations were acquired using 128 MDCT (GSI CT, GE) with a peak tube voltage of 120 kVp, tube current of 100 or 200 mA, and rotation times of 0.5 or 0.8 s. To confirm the imaging results, the FNAC was performed and for every nodule the following parameters were extracted: the presence of the solid component (named = 1), papillary component (named = 2), and mixed component (named = 3). Feature calculation was performed using the HealthMyne software and Integrated Platform That Enables Better Patient Management Decisions For Oncology. The radiologist uses the Rapid Precise Metrics (RPM)™ functionality to identify a lesion with the algorithm and these methods are put to work. The correlation between each feature and the tumor volume was calculated using a two-step cluster statistical analysis. In this retrospective study, in one year from 2018 to 2019 20 patients with lung adenocarcinoma confirmed with FNAC were enrolled. The pathologic results were subdivided into three categories: the solid architecture (group 1), papillary architecture (group 2), and mixed architecture (group 3). Nine lesions resulted with component 1, seven patients with component 2, and 3 patients with component 3. Eight females and 12 males with a median age 61 and 15 years (mean ± SD = 67.4 ± 9.7 years, range 39-73 years) were enrolled. The two results suggest, with p < 0.05, that the GGO variable is a good discriminating estimator of the kurtosis variable: GGO = "no" implies a high kurtosis value, while GGO = "yes" implies a low value. The numerous data obtained from the automatic analysis allow to have a fertile ground on which to develop a new concept of medicine which is precision medicine. The limit of this study is the poor sample. In the future, in order to have a more mature and consolidated discipline, it is necessary to increase the large scale of observations with further studies to establish the rigorous evaluation criteria. In order for radiomics to mature as a discipline in the future, it will be necessary to develop studies that consolidate its role to standardize the collected data.

Delta-radiomics increases multicentre reproducibility: a phantom study

Texture analysis (TA) can provide quantitative features from medical imaging that can be correlated to clinical endpoints. The challenges relevant to robustness of radiomics features have been analyzed by many researchers, as it seems to be influenced by acquisition and reconstruction protocols. Delta-texture analysis (D-TA), conversely, consist in the analysis of TA feature variations at different acquisition times, usually before and after a therapy. Aim of this study was to investigate the influence of different CT scanners and acquisition parameters in the robustness of TA and D-TA. We scanned a commercial phantom (CIRS model 467, Gammex, Middleton, WI, USA), that is used for the calibration of electron density, two times by varying the disposition of plugs, using three different scanners. After the segmentation, we extracted TA features with LifeX and calculated TA features and D-TA features, defined as the variation of each TA parameters extracted from the same position by varying the plugs with the formula (Y-X)/X. The robustness of TA and D-TA features were then tested with intraclass coefficient correlation (ICC) analysis. The reliability of TA parameters across different scans, with different acquisition parameters and ROI positions has shown poor reliability in 12/37 and moderate reliability in the remaining 25/37, with no parameters showing good reliability. The reliability of D-TA, conversely, showed poor reliability in 10/37 parameters, moderate reliability in 10/37 parameters, and good reliability in 17/37 parameters. The comparison between TA and D-TA ICCs showed a significant difference for the whole group of parameters (p:0.004) and for the subclasses of GLCM parameters (p:0.033), whereas for the other subclasses of matrices (GLRLM, NGLDM, GLZLM, Histogram), the difference was not significant. D-TA features seem to be more robust than TA features. These findings reinforce the potentiality for using D-TA features for early assessment of treatment response and for developing tailored therapies. More work is needed in a clinical setting to confirm the results of the present study.

Primary Hemangiopericytoma Arising in Extralobar Pulmonary Sequestration: A Coincidence or Two Rare Disorders?

BACKGROUND/AIM

Extralobar pulmonary sequestration (EPS) is an unusual congenital defect characterized by the presence of non-functioning lung tissue receiving arterial supply from the systemic arteries. Primary hemangiopericytoma (HPC) is an uncommon potentially malignant tumor of vascular origin that usually involves the soft tissue of the extremities or retroperitoneum, but extremely rarely affects the lung. We present the rare case of a primary pulmonary HPC arising in an EPS.

CASE REPORT

A 65-year-old woman, with dyspnea and pleuritic chest pain, was referred for further investigation. Radiological evaluation demonstrated a well-circumscribed mass above the right hemidiaphragm, receiving its arterial supply from the descending thoracic aorta. The patient underwent a right posterolateral thoracotomy and a middle lobectomy. The intraoperative finding was a well-encapsulated solid mass. The histological evaluation described HPC.

RESULTS

The patient remains fit and healthy.

CONCLUSION

Pulmonary HPC can arise in EPS. Surgical excision is the treatment of choice.

Intralobar pulmonary sequestration with cystic degeneration mimicking a bronchogenic cyst in an elderly patient: A case report and literature review

INTRODUCTION

Pulmonary sequestration (PS) is a rare congenital malformation defined as nonfunctioning lung tissue supplied by systemic circulation. It is uncommonly diagnosed in adults. Herein, we describe a clinical case of PS with cystic degeneration mimicking a bronchogenic cyst in an elderly patient.

PATIENT CONCERNS

A huge cystic mass was incidentally found in a 65-year-old man on chest computed tomography (CT) scans during preoperative workup for a hand laceration. A 15-cm-sized round cystic mass was detected in the right lower lobe.

DIAGNOSIS

After reviewing the chest CT scan, we decided to perform contrast-enhanced chest magnetic resonance imaging (MRI) and CT-guided lung aspiration biopsy. On MRI, the lesion had the appearance of a cystic mass with hemorrhagic clots, such as an intrapulmonary bronchogenic cyst. The aspirated specimen was nondiagnostic; thus, we decided to surgically remove the mass.

INTERVENTIONS

Upon right lower lobectomy, the mass was diagnosed as a PS. A thin systemic artery supplying the cystic mass was visualized during surgery.

OUTCOMES

The patient is undergoing regular follow-up at the outpatient clinic.

CONCLUSIONS

PS should be considered as a differential diagnosis in patients with a cystic lung mass. Identification of a systemic artery on radiologic imaging is important in the diagnosis of PS before preoperative workup to prevent unpredicted massive bleeding during surgery.

Percutaneous needle biopsy of retroperitoneal lesions: technical developments

Percutaneous Needle Biopsy (PNB) is the insertion of a needle into a suspected lesion or an organ with the aim to obtain cells or tissue for diagnosis. It’s a relatively non-invasive procedure and is performed by radiologist under guidance of imaging techniques such as ultrasound (US), computed tomography (CT), fluoroscopy, magnetic resonance imaging (MRI), and positron emission tomography CT (PET-CT). The choice of imaging technique depends on the evaluation of the target lesion and patient compliance. PNB includes two categories: fine-needle aspiration biopsy (FNAB) that is the use of a thin needle (18-25 gauge) to extract cells for cytological evaluation; and core needle biopsy (CNB) that is the use of a larger needle (9-20 gauge) to extract a piece of tissue for histological evaluation. The indications for biopsy are the characterization of nature (benign or malignant) of a lesion, diagnosis and staging of tumor, and biological or immunohistochemical/genetic analisys on tissue. Success of PNB is the procurement of sufficient material to characterize lesions and to guide the patient outcome. Major complications are rare. PNB became a useful technique in diagnosis and study of retroperitoneal lesions, because of a more suitable access to specific intra-abdominal structures, lowering the risk of injury of interposed structures (such as bowel, great vessels). (www.actabiomedica.it)

Magnetic resonance enterography (MRE) and ultrasonography (US) in the study of the small bowel in Crohn's disease: state of the art and review of the literature

Crohn’s disease (CD) is a chronic idiopathic disease and its diagnosis is based on a combination of clinical symptoms, laboratory tests and imaging data. There isn’t a diagnostic gold standard: the ileocolonoscopy with mucosal biopsies represents the standard for luminal disease, while cross-sectional imaging such as Ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) can show transmural alterations and extraintestinal manifestations. CD is usually diagnosed in the young age and after baseline diagnosis, the patients have to undergo to variable follow-up depending on remission or active disease. The aim of our review is to compare Magnetic Resonance Enterography (MRE) to Ultrasonography (US) in the follow-up of CD. (www.actabiomedica.it)

Internal hernias: a difficult diagnostic challenge. Review of CT signs and clinical findings

Although internal hernias are uncommon, they must be beared in mind in the differential diagnosis in cases of intestinal obstruction, especially in patients with no history of previous surgery or trauma. Because of the high possibility of strangulation and ischemia of the affected loops, internal hernias represent a potentially life-threatening condition and surgical emergency that needs to be quickly recognized and managed promptly. Imaging plays a leading role in the diagnosis and in particular multidetector computed tomography (MDCT), with its thin-section and high-resolution multiplanar reformatted (MPR) images, represents the first line image technique in these patients. The purpose of the present paper is to illustrate the characteristic anatomic location, the clinical findings and the CT appearance associated with main types of internal hernia, including paraduodenal, foramen of Winslow, pericecal, sigmoid-mesocolon- and trans-mesenteric-related, transomental, supravesical and pelvic hernias. (www.actabiomedica.it)

Diagnostic value/performance of radiological liver imaging during chemoterapy for gastrointestinal malignancy: a critical review

This article reviews the main toxic effect, complications and relative imaging findings of the liver that may appear during the oncologic follow up among patients affected by gastrointestinal malignancy. Awareness of the causative chemotherapeutic agent and regimens, pathophysiology and relative characteristic imaging findings of hepatic injuries is critical in order to obtain an accurate diagnosis especially when these parenchymal lesions are focal. An accurate synergic radiological diagnosis with Computed Tomography (CT) and Magnetic Resonance (MR) techniques may induce a potential termination of ineffective/toxic chemotherapy during early phases of treatment, changing the therapeutic plan in order to avoid first unnecessary liver biopsy and then invasive treatment as hepatic resection if not required.

Congenital cystic adenomatoid malformation in adults: Report of a case presenting with a recurrent pneumothorax and a literature review of 60 cases

Congenital cystic adenomatoid malformation (CCAM) is a congenital pulmonary cystic disease that is mostly detected and diagnosed prenatally or during the neonatal period, while rarely being observed in adults. Here, we report an adult case of CCAM that was diagnosed following surgery for a recurrent pneumothorax. We further review 60 case reports on adult CCAM that have been previously published. The patient was a 29-year-old woman with a severe left pneumothorax. Her computed tomography scan showed the presence of multiple pulmonary cysts at the base of the left lower lobe. Since she had experienced a left pneumothorax twice previously, surgery was indicated. A wedge lung resection of the pulmonary cysts was performed thoracoscopically. The postoperative pathological diagnosis was type I CCAM. From the review, 7 adult CCAM patients (11.7%) out of 61, including the patient in the present case, presented with pneumothorax, while 21 patients (35%) presented with infection. Thirty-nine foci of CCAM (65%) were located in lower lobes. Moreover, malignancies were associated in 8 cases (13.3%). We propose that if multicystic lung lesions are found in pneumothorax patients, particularly in lower lobes, CCAM should be considered during the differential diagnosis, even in adults.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures.

Imaging of pediatric foot disorders

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient’s comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn’t adequately define the bone’s non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique. (www.actabiomedica.it)

Radiofrequency versus microwave ablation for treatment of the lung tumours: LUMIRA (lung microwave radiofrequency) randomized trial

The LUMIRA trial evaluated the effectiveness of radiofrequency (RFA) and microwave ablation (MWA) in lung tumours ablation and defining more precisely their fields of application. It is a controlled prospective multi-centre random trial with 1:1 randomization. Fifty-two patients in stage IV disease (15 females and 37 males, mean age 69 y.o., range 40-87) were included. We randomized the patients in two different subgroups: MWA group and RFA group. For each group, we evaluated the technical and clinical success, the overall survival and complication rate. Inter-group difference was compared using Chi-square test or Fisher's exact test for categorical variables and one-way ANOVA test for continuous variables. For RFA group, there was a significant reduction in tumour size only between 6 and 12 months (p value = 0.0014). For MWA group, there was a significant reduction in tumour size between 6 and 12 months (p value = 0.0003) and between pre-therapy and 12 months (p value = 0.0215). There were not significant differences between the two groups in terms of survival time (p value = 0.883), while the pain level in MWA group was significantly less than in RFA group (1.79 < 3.25, p value = 0.0043). In conclusion, our trial confirms RFA and MWA are both excellent choices in terms of efficacy and safety in lung tumour treatments. However, when compared to RFA therapy, MWA produced a less intraprocedural pain and a significant reduction in tumour mass.

Videofluoroscopy and oropharyngeal manometry for evaluation of swallowing in elderly patients

Presbyphagia represents the physiological aging evolution of the swallowing function. It is related to the natural changes of the anatomical structures involved in the swallowing process. These age-related modifications can be asymptomatic in the early stages of life, but in the late stages, they could lead to dysphagia, aspiration pneumonia, dehydration, or malnutrition, reducing the quality of life. Videofluoromanometry (VFM) is the combined study of videofluoroscopy (VFS) and oropharyngeal manometry that allows simultaneous identification of functional and morphological features of the presbyphagia, also in asymptomatic otherwise healthy elderly adults. This study retrospectively evaluated the effectiveness of the VFM and the role of a multidisciplinary team of specialists in the analysis of a large cohort of old patients with presbyphagia, with the objective of achieving early diagnosis of the disease and the best therapy to delay the development of complications such as aspiration pneumonia, malnutrition, and dehydration.

Validation of DWI in assessment of radiotreated bone metastases in elderly patients

Bone metastases are commonly observed in oncologic patients with advanced disease. These metastases are considered the main cause of neoplastic pain, with more than half of oncologic patients experiencing neoplastic pain during the course of the disease due to bone involvement. Lung, breast, and prostate cancers are the primary causes of bone metastases. Magnetic resonance imaging (MRI), especially diffusion weighted imaging (DWI) sequences, is the focus of our research, as it has been proven to be an optimal predictive index to assess the radiation treatment in many patients. We included patients treated with standard fractioning of radiation therapy. First, we examined the irradiated lesions with the MRI-DWI technique, before treatment and 30 and 60 days after its completion. Then we combined the MRI results and clinical parameters in a table with a predictive score for the quality of life in patients with bone metastases. This was a significant predictor of the efficacy of radiation treatment, from both clinical and psychological points of view, as it can allow an early assessment of the response to RT and therefore better scheduling of the next therapeutic steps to be performed. The table of the score we proposed helped guide patient monitoring, enabling us to undertake, where possible, follow-up with therapeutic strategies tailored to each patient's needs.

Congenital pulmonary airway malformation and sequestration: Two standpoints for a single condition

In adults, congenital pulmonary malformations are candidates for surgery due to symptoms. A pre-natal diagnosis is simple and effective, and allows an early thoracoscopic surgical treatment. A retrospective study was performed to assess management in two different populations of adults and children to define the best strategy.

Imaging assessment of gunshot wounds

Gunshot injuries occur when someone is shot by a bullet or other sort of projectile from a firearm. Wounds are generally classified as low velocity (less than 609.6m/s) or high velocity (more than 609.6m/s). Those with higher velocity may be expected, on this basis, to dissipate more energy into surrounding tissue as they are slow and cause more tissue damage, but this is only a very approximate guide. However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as the kinetic energy, stability, entrance profile and path traveled through the body, and the biological characteristics of the tissues injured. Hemodynamically stable patients and patients who stabilized after simple immediate resuscitation were evaluated with a careful history and physical examination. A routine x-ray is performed in patients with gunshot wounds. Indication for total body computed tomography (CT) is based on the presence of signs and symptoms of vascular damage at clinical examination. Patients are immediately transferred in the operating room for surgery if more serious injuries that require immediate surgical care are not diagnosed, or hemostasis may be preliminary reached in the emergency room. Hemodynamically stable patients with no history and clinical examination showing suspected vascular damage are allowed in the radiology department for obtaining a total body CT scan with intravenous contrast medium and then transferred to the surgical ward trauma for observation. After 24 hours without the complications, patient can be discharged. CT is the procedure of choice to identify hemorrhage, air, bullet, bone fragments, hemothorax, nerve lesion, musculoskeletal lesions, and vessels injuries and is useful for assessing medicolegal aspects as trajectory and the anatomical structures at risk.

How the preoperative ultrasound examination and BFI of the cervical lymph nodes modify the therapeutic treatment in patients with papillary thyroid cancer

Background

Ultrasound is considered the best diagnostic method for the detection of metastatic cervical lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC). According to current guidelines, all patients undergoing thyroidectomy for malignancy should undergo preoperative neck ultrasound of the thyroid and central and lateral neck LNs, followed by fine needle aspiration of suspicious LNs. Cervical LN involvement determenes the extent of surgery. Complete surgical resection disease at the initial operation decreases likelihood of future surgery for recurrent disease and may impact survival. We use a new technique, B-flow imaging (BFI), recently used for evaluation of thyroid nodules, to estimate the presence of BFI twinkling signs (BFI-TS), within metastatic LNs in patients with PTC.

Methods

Between September 2006 and December 2012, 304 patients with known PTC were examined for preoperative sonographic evaluation with gray-scale US, color Doppler US and BFI. Only 157 with at least one metastatic LN were included in our study. All patients included underwent surgery, and the final diagnosis was based on the results of histologic examination of the resected specimens. The following LN characteristics were evaluated: LN shape, abnormal echogenicity, the absent of hilum, calcifications, cystic appearance, peripheral vascularization and the presence of BFI-TS.

Results

A total of 767 LNs were analyzed. 329 out of 767 were metastatic, according to the histopathologic findings. BFI-TS, showed 99.5% specificity and 81,5% sensitivity. We detected BFI-TS in 6 metastatic LNs that were negative to the other conventional US features.

Conclusions

Our results indicate that the BFI-TS has a diagnostic accuracy higher than the other conventional sonographic signs. Our findings suggest that BFI can be helpful in the selection of suspicious neck LNs that should be examined at cytologic examination or open biopsy for accurate preoperative staging and individual therapy selection.

The clinical value of computer tomographic angiography for the diagnosis and therapeutic planning of patients with pulmonary sequestration

OBJECTIVES

This study was conducted to evaluate the clinical value of computed tomographic (CT) angiography for diagnosis and therapeutic planning in patients with pulmonary sequestration.

METHODS

Forty-three patients with suspected pulmonary sequestration underwent CT angiography before undergoing digital subtraction angiography or surgery. For each patient, CT angiography was used to determine whether the pulmonary sequestration was suitable for coil embolization, surgical resection or conservative treatment. The treatments planned using CT angiography were compared with actual treatment decisions made or treatments administered using digital subtraction angiography or surgery.

RESULTS

Digital subtraction angiography and/or surgery confirmed pulmonary sequestration in 37 patients; six patients had no pulmonary sequestration. The diagnostic performance of CT angiography for pulmonary sequestration in the patient-based evaluation yielded an accuracy of 97.7%, sensitivity of 97.3%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 85.7%. The aberrant systemic artery-based evaluation yielded an accuracy of 98.0%, sensitivity of 97.8%, specificity of 100%, PPV of 100% and NPV of 85.7%. Treatments could be correctly planned using CT angiography with 100% accuracy, sensitivity, specificity, PPV and NPV according to the aneurysm-based evaluation.

CONCLUSIONS

We have obtained promising results with a CT angiography-based protocol, rather than a digital subtraction angiography-based protocol, as the only diagnostic and pretreatment planning tool in patients with pulmonary sequestration. The CT angiography-based selection of treatment strategies seems to be safe and effective in the majority of patients with pulmonary sequestration.