Alessandro Garlaschi

Seronegative Spondyloarthropathies: what radiologists should know.

Inflammatory involvement of the spine and sacroiliac joints is the most peculiar feature of seronegative spondyloarthropathies (SpA), which include ankylosing spondylitis, psoriatic arthritis, reactive arthritis (Reiter’s syndrome), enteropathic spondylitis (related to inflammatory bowel diseases) and undifferentiated spondyloarthropathies. SAPHO syndrome may also be considered a SpA, but there is no clear agreement in this respect. Imaging, along with clinical and laboratory evaluation, is an important tool to reach a correct diagnosis and to provide a precise grading of disease progression, influencing both clinical management and therapy. Conventional radiography, which is often the first-step imaging modality in SpA, does not allow an early diagnosis. Computed tomography (CT) demonstrates with a very high spatial resolution the tiny structural alterations of cortical and spongy bone before they become evident on plain film radiographs. Magnetic resonance imaging (MRI) is the only modality that provides demonstration of bone marrow oedema, which reflects vasodilatation and inflammatory hyperaemia. The primary aim of this review article was to examine the involvement of the spine and sacroiliac joints in SpA using a multimodal radiological approach (radiography, CT, MRI), providing a practical guide for the differential diagnosis of these conditions.

Magnetic resonance imaging of breast cancer: factors affecting the accuracy of preoperative lesion sizing

Background Accurate preoperative sizing of breast cancer with imaging modalities has a great importance in the surgical planning. Purpose To assess the influence of tumor size and histology on the accuracy of measurement of cancer local extension by magnetic resonance imaging (MRI). Material and Methods One hundred and eighty-six patients with primary breast cancer, for a total of 221 lesions, were included in this retrospective study. Tumors were divided into five histological groups: invasive ductal carcinoma (IDC), IDC with extensive intraductal component (EIC), invasive lobular carcinoma (ILC), ductal carcinoma in situ (DCIS), and “other histology” (mucinous, papillary, medullary, tubular, and apocrine breast cancer). Microscopic measurement of the largest diameter of tumors at pathology was chosen as reference standard and compared with MRI measurement. Concordance was defined as a difference ≤ 5 mm between MRI and pathology. Results The mean size of tumors at pathology was 24.8 ± 19.4 mm, while at MRI it was 29.7 ± 20 mm (P < 0.05), with a significant overestimation of MRI. MRI–pathology concordance was found in 98/221 cases (44.3%), while MRI overestimated the size of 81/221 tumors (36.7%). The extent of overestimation was significantly different among the five histological groups (P < 0.05). At multivariate analysis, DCIS histology was the factor more significantly associated with MRI–pathology discordance (P = 0.0005), while the influence of tumor dimension at pathology was less significant (P = 0.0073). Conclusion DCIS histology is strongly associated with discordance between MRI and pathology sizing of breast cancer. Lesion size can also influence the accuracy of MRI measurements, but to a lesser extent.

Quantitative Analysis of Lung Ultrasonography for the Detection of Community-Acquired Pneumonia: A Pilot Study

Background and Objective. Chest X-ray is recommended for routine use in patients with suspected pneumonia, but its use in emergency settings is limited. In this study, the diagnostic performance of a new method for quantitative analysis of lung ultrasonography was compared with bedside chest X-ray and visual lung ultrasonography for detection of community-acquired pneumonia, using thoracic computed tomography as a gold standard. Methods. Thirty-two spontaneously breathing patients with suspected community-acquired pneumonia, undergoing computed tomography examination, were consecutively enrolled. Each hemithorax was evaluated for the presence or absence of abnormalities by chest X-ray and quantitative or visual ultrasonography. Results. Quantitative ultrasonography showed higher sensitivity (93%), specificity (95%), and diagnostic accuracy (94%) than chest X-ray (64%, 80%, and 69%, resp.), visual ultrasonography (68%, 95%, and 77%, resp.), or their combination (77%, 75%, and 77%, resp.). Conclusions. Quantitative lung ultrasonography was considerably more accurate than either chest X-ray or visual ultrasonography in the diagnosis of community-acquired pneumonia and it may represent a useful first-line approach for confirmation of clinical diagnosis in emergency settings.

Splenic Doppler resistive index for early detection of occult hemorrhagic shock after polytrauma in adult patients.

ABSTRACT The objective of this study was to evaluate whether direct assessment of splenic circulation by splenic Doppler resistive index (Doppler RI) is a clinically useful noninvasive method for an early detection of occult hemorrhagic shock after polytrauma in adult patients. Splenic Doppler RI was measured in 49 hemodynamically stable adult patients admitted to the emergency department because of polytrauma. Renal Doppler RI was also determined in 20 patients. Spleen size, Injury Severity Score, systolic blood pressure, heart rate, blood lactate, standard base excess, pH, hemoglobin, and inferior vena cava diameter values were recorded at admission and at 24 h. Patients were grouped according to whether signs of hemorrhagic shock did (n = 22) or did not (n = 27) occur within the first 24 h from admission. Patients who developed hemorrhagic shock had significantly higher splenic and renal Doppler RI, higher Injury Severity Score, and lower standard base excess at admission. By multivariate logistic regression, splenic Doppler RI resulted to be a predictor of hemorrhagic shock development within the first 24 h from admission. Splenic Doppler RI may represent a clinically useful noninvasive method for early detection of occult hemorrhagic shock and persistent occult hypoperfusion after polytrauma in adult patients.

Crohn's disease recurrence in patients with ileocolic anastomosis: Value of computed tomography enterography with water enema

OBJECTIVES The main objective of the present work was to determine the diagnostic value of CT-enterography with water enema (CTe-WE) in the assessment of the ileocolic anastomosis in patients with Crohns disease (CD). The prevalence of synchronous inflammatory lesions (SILs) involving gastrointestinal segments distinct from the anastomosis was also determined. Further, the association between the type of ileocolic anastomosis and the behavior (i.e. inflammatory, stricturing, penetrating) of CD recurrence was evaluated. METHODS 51 patients were retrospectively included (26 [51%] male and 25 [49%] female; mean age: 52.88 years ± 13.35). Ileocolic anastomoses were: 18 (35.3%) stapled side-to-side, 17 (33.3%) end-to-side, and 16 (31.4%) end-to-end. CTe-WEs were reviewed in consensus by two gastrointestinal radiologists. Endoscopy and medical records were used as reference standards. RESULTS CTe-WE yielded 95.35% sensitivity (CI 95%: 84.19-99.43%), 75.00% specificity (CI 95%: 34.91-96.81%), and 92.15% diagnostic accuracy (CI 95%: 81.31-98.02%). Anastomotic recurrence was found in 41/51 (80.4%) patients, including 30/41 (73.2%) cases of isolated anastomotic recurrence, and 11/41 (26.8%) cases of anastomotic recurrence with a SIL. A significant lower prevalence of stricturing recurrence was observed in patients with stapled side-to-side anastomoses (p=0.033). CONCLUSIONS CTe-WE provides a good distension of both sides of ileocolic anastomoses allowing the detection of SILs.

Mechanisms for reduced pulmonary diffusing capacity in haematopoietic stem-cell transplantation recipients

Lung diffusing capacity for CO (DLCO) is compromised in haematopoietic stem-cell transplantation (HSCT) recipients. We derived alveolar-capillary membrane conductance (DM,CO) and pulmonary capillary volume (VC) from DLCO and diffusing capacity for NO (DLNO). Forty patients were studied before and 6 weeks after HSCT. Before HSCT, DLNO and DLCO were significantly lower than in 30 healthy controls. DM,CO was ∼40% lower in patients than in controls (p<0.001), whereas VC did not differ significantly. After HSCT, DLNO and DM,CO further decreased, the latter by ∼22% from before HSCT (p<0.01) while VC did not change significantly. Lung density, serum CRP and reactive oxygen metabolites were significantly increased, with the latter being correlated (R2=0.71, p<0.001) with the decrement in DLNO. We conclude that DLNO and, to a lesser extent, DLCO are compromised before HSCT mainly due to a DM,CO reduction. A further reduction of DM,CO without VC loss occurs after HSCT, possibly related to development of oedema, or interstitial fibrosis, or both.

Lung function testing in COPD: when everything is not so simple

Combined pulmonary fibrosis and emphysema is a condition occurring mainly in male smokers, presenting different lung mechanics and gas exchange abnormalities than emphysema or pulmonary fibrosis alone. We report the case of an elderly man, former heavy smoker, who presented with progressive exertional dyspnea for 1 year. Lung function tests showed near normal spirometry and lung volumes but marked reduction of diffusing capacity for carbon monoxide and even more nitric oxide. The arterial partial pressure of oxygen was reduced with a markedly increased alveolar‐to‐arterial difference. High‐resolution computed tomography of the chest showed a pattern consistent with upper lobe emphysema and lower lobe pulmonary fibrosis. In conclusion, this case report confirms the limitations of a simplistic approach to lung function in the diagnosis of symptomatic smokers.

Lung diffusing capacity for nitric oxide as a marker of fibrotic changes in idiopathic interstitial pneumonias.

Lung diffusing capacity for carbon monoxide (DLCO) is decreased in both usual interstitial pneumonia-idiopathic pulmonary fibrosis (UIP-IPF) and nonspecific interstitial pneumonia (NSIP), but is moderately related to computed tomography (CT)-determined fibrotic changes. This may be due to the relative insensitivity of DLCO to changes in alveolar membrane diffusive conductance (DMCO). The purpose of this study was to determine whether measurement of lung diffusing capacity for nitric oxide (DLNO) better reflects fibrotic changes than DLCO DLNO-DLCO were measured simultaneously in 30 patients with UIP-IPF and 30 with NSIP. Eighty-one matched healthy subjects served as a control group. The amount of pulmonary fibrosis was estimated by CT volumetric analysis of visually bounded areas showing reticular opacities and honeycombing. DMCO and pulmonary capillary volume (VC) were calculated. DLNO was below the lower limit of normal in all patients irrespective of extent and nature of disease, whereas DLCO was within the normal range in a nonnegligible number of patients. Both DLNO and DLCO were significantly correlated with visual assessment of fibrosis but DLNO more closely than DLCO DMCO was also below the lower limit of normal in all UIP-IPF and NSIP patients and significantly correlated with fibrosis extent in both diseases, whereas VC was weakly correlated with fibrosis in UIP-IPF and uncorrelated in NSIP, with normal values in half of patients. In conclusion, measurement of DLNO may provide a more sensitive evaluation of fibrotic changes than DLCO in either UIP-IPF or NSIP, because it better reflects DMCO.

Freehand 3T MR-guided vacuum-assisted breast biopsy (VAB): a five-year experience

Background Magnetic resonance (MR) permits the detection of some malignant lesions that cannot be identified with mammography or ultrasonography. The characterization of these MR-only detectable lesions often requires a biopsy. Purpose To evaluate the technique, the feasibility and the accuracy of freehand 3T MR-guided VAB for the characterization of suspicious, MR-only detectable lesions and to compare VAB results with surgical pathology and follow-up imaging results. Material and Methods During 2010–2015, 118 women who were referred for MR-guided VAB were retrospectively reviewed. All BI-RADS MR 4 and 5 lesions and some BI-RADS MR 3 lesions (according to clinical context and patient anxiety) were scheduled to undergo biopsy. Results A total of 123 suspicious lesions were retrospectively selected. Technical failures occurred in only two cases (1.6%) due to the location of the lesions. Histopathological results revealed 59 benign lesions (48%), 27 high-risk lesions (22%), and 35 malignant lesions (28.4%). Surgical pathology results led to the reclassification of eight B3 lesions: one proved to be a ductal carcinoma in situ, while seven presented with invasive features. B3 underestimation also occurred in 29% of the cases. MR follow-up was achieved for all the benign lesions and no false-negative cases were observed. No complications, 3T-related artefacts, or difficulties were observed. Conclusion Freehand 3T MR-guided VAB was found to be a valid, safe, fast, and inexpensive alternative to surgical histology.

Magnetic resonance imaging of breast cancer: does the time interval between biopsy and MRI influence MRI–pathology discordance in lesion sizing?

Background Breast magnetic resonance imaging (MRI) is more accurate than ultrasound and mammography in estimating local extension of both invasive breast cancer and ductal carcinoma in situ (DCIS) and it is part of a breast cancer patient’s preoperative management. Purpose To verify if time interval between breast biopsy and preoperative MRI, lesion margins, and biopsy technique can influence tumor sizing on MRI. Material and Methods By a database search, we retrospectively identified all women with a newly diagnosed, biopsy-proven, primary breast cancer who underwent MRI before surgery. The time interval between biopsy and MRI, the type of biopsy procedure, and various pathological features of tumors were collected. We defined the concordance between MRI and pathology measurements as a difference of <5 mm in lesion sizing. Results One hundred and sixty-six women (mean age, 51.4 ± 10.4 years) were included. The time interval between biopsy and MRI showed only a weak correlation with the absolute MRI–pathology difference (r = 0.236). Stratifying the whole cohort of patients using a cutoff value of 30 days, we found that the MRI–pathology discordance was significantly higher in patients with a biopsy–MRI time interval >30 days (P < 0.05). By means of multivariate analysis, we found that DCIS subtype and the presence of poorly defined margins on MRI are the only two factors independently and strongly associated with MRI–pathology discordance in lesion sizing. Conclusion Size, histology, and margins of tumors may affect the accuracy of MRI measurements. The type of biopsy procedure and the time interval between biopsy and preoperative MRI are not independently associated to MRI–pathology discordance.