Eugenio Salizzoni

Preoperative local staging of endometrial cancer: transvaginal sonography vs. magnetic resonance imaging.

To compare the accuracy of transvaginal sonography (TVS) and magnetic resonance imaging (MRI) in the preoperative staging of endometrial carcinoma.

Accuracy, reproducibility and repeatability of ultrasonography in the assessment of abdominal adiposity.

RATIONALE AND OBJECTIVES Despite improvements in the methods used in body composition analysis, some goals remain far from clinical practice. Among them, the most important is the quantification of intra-abdominal adipose tissue. Fat distribution is a key point in the assessment of cardiovascular and metabolic risk status. The aim of this study was to define the accuracy, reproducibility, and repeatability of ultrasonography in the evaluation of abdominal adiposity. MATERIALS AND METHODS Twenty-six nonobese patients (group A) who underwent computed tomographic (CT) abdominal imaging and 29 obese patients (group B) were enrolled. Patients from both groups were independently evaluated using ultrasound by three radiologists; computed tomography-like conditions were reproduced, and six main parameters of subcutaneous and internal adiposity were measured (as well as three derived indexes) with both linear and convex probes. In group A, the same measurements were also obtained on CT images. Time spent for every ultrasound session was recorded. Results were analyzed using Lins concordance correlation (ρ), intraclass correlation, and linear regression analysis (and analysis of variance). RESULTS Three patients were excluded from group A after CT scans because of technical problems. Mesenteric fat thickness did not show significant correlations and reliability. Strong correlations between ultrasound and CT measurements were observed for all other visceral and subcutaneous parameters (ρ = 0.85-0.96). Intraobserver and interobserver agreement was excellent in both groups (repeatability: ρ = 0.83-0.99 for group A, ρ = 0.90-0.99 for group B; reproducibility: intraclass correlation coefficient = 0.90-0.99 for groups A and B). The mean time spent was 95 ± 21 seconds for group A (mean body mass index, 27.4 ± 2.4 kg/m(2)) and 129 ± 33 seconds for group B (mean body mass index, 37.3 ± 11.9 kg/m(2)). CONCLUSIONS Ultrasound is accurate, reproducible, and fast in the analysis of abdominal adiposity. It offers a regional, easy, and close-at-hand evaluation of subcutaneous and visceral fat compartments. This should be taken into consideration when clinical routine examinations are performed or to evaluate patients with specific metabolic diseases before and after treatment.

Contrast enhanced MRI and 18F-FDG PET-CT in the assessment of multiple myeloma: A comparison of results in different phases of the disease

OBJECTIVES The aim of our study was to compare the accuracy of contrast enhanced MRI and FDG PET-CT in the staging, treatment evaluation and follow-up of multiple myeloma. METHODS We retrospectively reviewed 210 PET-CT and 210 MRI studies of patients affected by multiple myeloma. MRI was always performed within 15 days of PET-CT. All the images have been evaluated by two expert oncologic radiologists. RESULTS Patient population included 81 females and 110 males (age 61.9 ± 9.9 years-old). Sixty-two patients have been evaluated at diagnosis, 58 at the end of therapies and 90 during follow-up. In 12/62 patients (19.4%) at diagnosis, differences between MRI and PET-CT findings determined changes in the staging: PET-CT was responsible for 11 down-staging (17.7%) and MRI only for one (1.6%). In 27/40 patients (67.5%) with good or complete clinical response to therapies the normalization of findings was faster for PET-CT than MRI. Ten out of 90 patients (10/90 - 11.1%) in follow-up protocol presented clinical recurrence of the disease: MRI detected active lesions in 8 of them (80.0%) and PET-CT in 5 patients (50.0%, all detected by MRI too). CONCLUSIONS MRI achieved better results than PET-CT in the staging and in patients with multiple myeloma recurrence. PET-CT, showed prompt change of imaging findings, faster than MRI, in patients with positive response to therapy.

Accuracy of MRI/MRSI-based transrectal ultrasound biopsy in peripheral and transition zones of the prostate gland in patients with prior negative biopsy

The purpose of the study was to evaluate the accuracy of transrectal ultrasound biopsy (TRUS‐biopsy) performed on regions with abnormal MRI and/or MRSI for both the transition (TZ) and the peripheral (PZ) zones in patients with suspected prostate cancer with prior negative biopsy, and to analyze the relationship between MRSI and histopathological findings. MRI and MRSI were performed in 54 patients (mean age: 63.9 years, mean PSA value: 11.4 ng/mL) and the ability of MRI/MRSI‐directed TRUS biopsy was evaluated. A three‐point score system was used for both techniques to distinguish healthy from malignant regions. Descriptive statistics and ROC analyses were performed to evaluate the accuracy and the best cut‐off in the three‐point score system. Twenty‐two out of 54 patients presented cancer at MRI/MRSI‐directed TRUS biopsy, nine presented cancer only in PZ, eight both in PZ and TZ, and five exclusively in TZ. On a patient basis the highest accuracy was obtained by assigning malignancy on a positive finding with MRSI and MRI even though it was not significantly greater than that obtained using MRI alone (area under the ROC curve, AUC: 0.723 vs 0.676). On a regional (n = 648) basis the best accuracy was also obtained by considering positive both MRSI and MRI for PZ (0.768) and TZ (0.822). MRSI was false positive in 11.9% of the regions. Twenty‐eight percent of cores with prostatitis were false positive findings on MRSI, whereas only 2.7% of benign prostatic hyperplasia was false positive. In conclusion, the accuracy of MRI/MRSI‐directed biopsies in localization of prostate cancer is good in patient (0.723) and region analyses (0.768). The combination of both MRI and MRSI results makes TRUS‐biopsy more accurate, particularly in the TZ (0.822) for patients with prior negative biopsies. Histopathological analysis showed that the main limitation of MRSI is the percentage of false positive findings due to prostatitis. Copyright

A 360-degree overview of body composition in healthy people: Relationships among anthropometry, ultrasonography, and dual-energy x-ray absorptiometry

OBJECTIVE The aim of this study was to test the relationship between anthropometry, ultrasonography, and dual-energy x-ray absorptiometry (DXA) for the assessment of body composition in clinical practice. METHODS The study was carried out in Italian blood donor volunteers belonging to five different age groups (18-70 y old; 25 men and 25 women per group; N = 250 participants; n = 125 men, n = 125 women). A complete history was collected and routine blood analyses were performed to confirm healthy status. All participants were submitted to whole-body DXA (tricompartmental analysis, regional, and total body), ultrasonography (abdominal adiposity evaluation), and anthropometric measurements. DXA was used as gold standard and its biomarkers were taken as reference for fat-lean mass balance, central-peripheral fat distribution, central or visceral fat, and subcutaneous fat. RESULTS Anthropometric and ultrasound parameters were closely associated with most of DXA parameters. Composite markers representative of central and abdominal visceral fat compartments were significantly correlated with waist circumference, waist-to-hip ratio, and intra-abdominal fat thickness by ultrasound, in both men and women (P < 0.025). As expected, subcutaneous depots were significantly correlated with maximum subcutaneous fat thickness measured by ultrasonography (P < 0.025). CONCLUSIONS Both anthropometry and ultrasonography provide a reliable estimate of visceral adipose tissue in a non-obese population compared with DXA, whereas anthropometry prediction of subcutaneous adiposity is weak. Physicians should be aware of the limits of these techniques for the assessment of body composition.

Can pancreatic steatosis explain the finding of pancreatic hyperenzymemia in subjects with dyslipidemia

Objective: It has been proposed by some investigators that benign pancreatic hyperenzymemia could result from pancreatic steatosis that they believe would have been caused by dyslipidemia; their diagnosis of steatosis was based on the finding of a hyperechogenic pancreas at ultrasound. The aim of this study was to assess the validity of this proposed model. Methods: The study group was composed of 18 subjects with benign pancreatic hyperenzymemia, 12 men and 6 women; mean age, 55 years; range, 38 to 68 years. All 18 had dyslipidemia and 9 had hyperechogenic pancreas at ultrasound. In addition, 6 subjects with benign pancreatic hyperenzymemia but who did not have dyslipidemia or hyperechogenic pancreas and 10 healthy subjects with none of these conditions were also studied as controls. In each of these subjects, magnetic resonance imaging of the pancreas was performed to assess the presence of pancreatic steatosis. Results: Magnetic resonance imaging showed normal pancreas with no signs of fatty infiltration in all 18 subjects with dyslipidemia, including those with both dyslipidemia and hyperechogenic pancreas at ultrasound. A similar result was found in all control subjects. Conclusion: The finding of a completely normal pancreas at magnetic resonance imaging does not support the proposed model in which pancreatic hyperenzymemia in subjects with dyslipidemia is attributed to pancreatic steatosis.

Magnetic resonance cholangiopancreatography in asymptomatic pancreatic hyperenzymemia.

Objectives: To determine the type and frequency of pancreatic lesions detected by magnetic resonance cholangiopancreatography (MRCP) in subjects with asymptomatic pancreatic hyperenzymemia and to assess for a possible relationship between these lesions and the hyperenzymemia. Methods: From January 2005 to May 2008, 63 subjects with asymptomatic pancreatic hyperenzymemia were studied by MRCP. In addition, amylase, pancreatic isoamylase, and lipase were determined for 5 consecutive days. Results: In most subjects (n = 57, 90.5%), MRCP showed a normal pancreas. In the remaining 6 subjects (9.5%), the following alterations were found: pancreas divisum in 2, small intrapancreatic cyst in 2, anatomic variant of the Wirsung in 1, and mild dilatation of 3 secondary ducts in 1. In these 6 subjects, hyperenzymemia was highly variable from day to day, with frequent normalizations, as was also true for the 30 subjects with no MRCP alterations in whom diurnal enzyme determinations were made. Conclusions: Most of the subjects with asymptomatic pancreatic hyperenzymemia did not have pancreatic lesions detectable by MRCP. In the few subjects in whom a lesion was found, the great variability and the frequent transient normalization of serum enzyme levels tend to exclude a relation between the lesion and the hyperenzymemia.

Role of color Doppler ultrasonography in the preoperative staging of pancreatic cancer.

We describe our experience with color Doppler ultrasonography (CDU) in the preoperative staging of pancreatic cancer and, particularly, in detecting the involvement of the portal-mesenteric trunk (PMT). Of the 54 patients studied, 43 (79.6%) underwent surgery and 11 (20.4%) did not because of evident infiltration of the PMT. Of the 43 patients operated on, the CDU study was normal in 8 cases (18.6%), abnormal in 33 (76.7%), and not possible in the remaining 2 cases (4.7%). Results of the CDU were confirmed intraoperatively in 39 cases (diagnostic accuracy, 95.1%). In only two cases (4.9%) did the CDU not show involvement of the PMT, which was, instead, demonstrated by intraoperative ultrasonography (false negatives). Of the 11 nonoperated patients, all showed morphological alterations at CDU, while only 7 showed hematic flow changes. The sensitivity of CDU was 94.2% and the specificity 100%. The positive predictive value was 100%; the negative predictive value, 75%. The results indicate that CDU may be the first imaging technique for preoperative assessment of PMT involvement in pancreatic cancer.

Involvement of Cricoarytenoid Joints in Rheumatoid Arthritis

A 76-year-old man who was previously diagnosed with rheumatoid arthritis (RA) with juvenile onset and active polyarticular erosive arthritis involving hands, wrists, and metatarsal-falangeal joints came to our observation for bilateral paralysis of vocal cords. He was on treatment with deflazacort (7.5 mg/d) and indomethacin (25 mg/bid); methotrexate (12.5 mg/wk) was previously stopped after developing pulmonary fibrosis. He entered for acute respiratory failure with dyspnea and stridor which had never occurred before. A direct laryngoscopy evidenced bilateral paralysis of vocal cord, fixed in adduction with consequent insufficient glottic respiratory space. He underwent emergency tracheostomy. Laboratory analysis showed high levels of CRP (9.24 mg/dL), RF (568 IU/ml), and ESR (46 mm/h); he was also positive to anti-CCP (60 U.A.). High resolution CT (HRCT) scan of the larynx with bone algorithm was performed and revealed erosions of the arytenoid cartilage in correspondence of the cricoarytenoid (CA) joints surface (arrows). Cricoarytenoid arthritis secondary to RA with airway compromise was diagnosed. Leflunomide (20 mg/d) was added in therapy plan with significant improvement of clinical conditions. The CA joint is a true diarthrodial articulation formed by the cricoid and arytenoid cartilages. As in other diarthrodial joints, synovial membranes line the surfaces and synovial fluid fills the space enclosed by the fibrous joint capsule. Cricoarytenoid arthritis occurs most commonly in rheumatoid disease. Other etiologies include gout, disseminated lupus erythematosus, scleroderma, Tietze syndrome, upper respiratory tract infections, trauma, and vocal cord tumors. Clinical manifestations of rheumatoid arthritis in the CA joint are uncommon and symptoms can be vague (sensation of a foreign body, fullness or tension in the throat hoarseness, odynophagia, and pain with speaking or coughing), absent, or masked by concomitant joint involvement. The most common CT findings include the presence of cricoarytenoid erosion, luxation, prominence, and abnormal position of the true vocal cord. CT imaging plays an integral role in the assessment of the CA joint in patient with RA.

Localizer sequences of magnetic resonance imaging accurately identify osteoporotic vertebral fractures

The aim of the present study was to evaluate the performance of sagittal MR localizer (MR-loc), in terms of diagnostic accuracy and intra- and inter-observer agreement in the detection of vertebral fractures (VFs). Three-hundred MR examinations of the thoracic and/or lumbar spine were randomly collected. A semi-quantitative approach was used and morphometric analysis was performed when a VF was suspected. MR-loc images were evaluated blindly by three radiologists in two different sessions. A full diagnostic sagittal T1-weighted fast spin echo MR sequence was used as standard of reference (RS). Degenerative arthritis was also scored on RS. Only vertebral bodies which were assessable by both MR-loc and RS were considered for the analysis. Area under the receiver operating characteristic curve (AUROC), Cohen kappa statistic, and linear-by-linear association were used for statistical analysis. Kappa values were compared by means of the z distribution. A total of 2186 vertebrae were analysed in 300 MRI exams (147 males, 153 females, 59.4±16.4y.o.). Sixty-seven out of 2136 (3.1%) VFs were identified in 23/300 (7.7%) patients submitted to MRI. In the detection of VFs, sensitivity and specificity of MR-loc were both 100% (accuracy AUROC=1.000). Inter-observer agreement was excellent (k=0.938±0.013), while intra-observer agreement was perfect (k=1.000). The diagnostic performance was independent from degenerative arthritis, vertebral level, type and grade of VFs. MR-loc is a simple but accurate tool in the detection of VFs. It should be introduced for systematic evaluation in the detection of VFs in MR examinations performed in daily clinical practice.