Federica Ciccarese

Selective arterial embolisation for bone tumours: experience of 454 cases

PurposeThe authors present the experience of a single institution with selective arterial embolisation for primary and metastatic bone tumours.Materials and methodsA total of 365 patients were treated with 454 embolisation procedures from December 2002 to April 2010. Embolisation was the primary treatment for benign bone tumours, adjuvant treatment to surgery for benign and malignant bone tumours and palliative treatment for bone sarcomas and metastases. Indications for repeat embolisation included pain or imaging evidence of progressive disease: 105 patients had repeat embolisation at the same location at an interval of 1–3 months; 260 patients had one embolisation, 78 had two and 29 had three or more. In all patients, N-2-butyl cyanoacrylate (NBCA) in 33% lipiodol was the embolic agent used.ResultsA total of 419 of the 454 embolisations (93%) were technically successful. In 35 cases, embolisation was not feasible because of poor lesion vascularisation (21 patients with bone metastases and two with aneurysmal bone cysts), origin of the Adamkiewicz artery in the embolisation field (four patients with bone metastases and one with aneurysmal bone cyst), atheromatosis and arteriosclerosis (five patients with bone metastases) and anatomical and technical problems such as small-calibre vessels, many branches and acute vessel angles (two patients with bone metastases). A clinical response was achieved in 406 of the 419 procedures (97%), and no response in 13 procedures in patients with pelvis and sacrum tumours. Complications included postembolisation syndrome in 81 patients (22%), transient paraesthesias in 41 (11%), skin breakdown and subcutaneous necrosis at the shoulder and pelvis in five (1.4%) and paresis of the sciatic nerve in one (0.3%).ConclusionsWe recommend embolisation as primary or palliative treatment or an adjunct to surgery for tumours of variable histology. Strict adherence to the principles of transcatheter embolisation is important. Arteries feeding the tumour and collaterals must be evaluated carefully and catheterised superselectively to protect the normal tissues. NBCA is considered the most appropriate embolic agent for small-vessel occlusion without major complications.RiassuntoObiettivoScopo del nostro lavoro è presentare l’esperienza di una singola istituzione nell’embolizzazione arteriosa selettiva dei tumori primitivi e delle metastasi dell’apparato muscolo-scheletrico.Materiali e metodiTrecentosessantacinque pazienti sono stati sottoposti a 454 embolizzazioni da dicembre 2002 a aprile 2010. L’embolizzazione è stata usata come trattamento primario per pseudo-tumori e tumori benigni, con significato adiuvante nel trattamento dei tumori maligni e nelle forme benigne e con significato palliativo nel trattamento dei sarcomi dell’osso e delle lesioni metastatiche. Il dolore e l’evidenza all’imaging di una progressione di malattia era l’indicazione per la ripetizione dell’embolizzazione; 105 hanno ripetuto l’embolizzazione nella stessa sede, ad intervallo di 1–3 mesi; 260 pazienti sono stati sottoposti ad una sola embolizzazione, 78 pazienti a due embolizzazioni e 29 pazienti a tre o più embolizzazioni. In tutti è stato usato come unico agente embolizzante l’N-2-butil-Cianoacrilato (NBCA) diluito con lipiodol al 33%.RisultatiQuattrocentodiccianove embolizzazioni (93%) sono state portate a termine con successo. Si è ottenuta risposta clinica in 406 procedure (97%) e nessuna risposta in 13 procedure in pazienti con tumori del bacino e del sacro. In 35 pazienti non è stata eseguita alcuna embolizzazione: in 21 pazienti con metastasi e in 2 con cisti aneurismatiche per scarsa vascolarizzazione; in 4 con metastasi ossea ed in 1 con cisti aneurismatica per la presenza di arteria di Adamkiewicz nella vascolarizzazione della lesione; in 5 pazienti con metastasi ossee per problemi steno-ostruttivi su base ateromasica; in 2 pazienti con metastasi per problemi tecnici legati al calibro dei vasi. Per quanto riguarda le complicazioni, in 81 pazienti (22%) è stata osservata una sindrome post-embolica, in 41 pazienti (11%) paresi transitoria, in cinque pazienti (1,4%) necrosi cutanea e sottocutanea di spala e pelvi, e in un paziente (0,3%) è stata riscontrata una paresi transitoria del nervo sciatico.ConclusioniRaccomandiamo l’embolizzazione per tumori ossei di varia istologia come trattamento primario, adiuvante o palliativo. È fondamentale un rigorosa adesione ai principi delle tecniche di embolizzazione. I vasi afferenti alla lesione vanno attentamente valutati e cateterizzati in maniera altamente selettiva al fine di proteggere i tessuti non lesionali. L’NBCA è, a nostro avviso, l’agente embolizzante più adatto per l’occlusione di piccoli vasi in assenza di complicanze maggiori, ma richiede buona esperienza da parte degli operatori.

Overview of current lung imaging in acute respiratory distress syndrome

Imaging plays a key role in the diagnosis and follow-up of acute respiratory distress syndrome (ARDS). Chest radiography, bedside lung ultrasonography and computed tomography scans can provide useful information for the management of patients and detection of prognostic factors. However, imaging findings are not specific and several possible differential diagnoses should be taken into account. Herein we will review the role of radiological techniques in ARDS, highlight the plain radiological and computed tomography findings according to the pathological stage of the disease (exudative, inflammatory and fibroproliferative), and summarise the main points for the differential diagnosis with cardiogenic oedema, which is still challenging in the acute stage.

Post-ARDS pulmonary fibrosis in patients with H1N1 pneumonia: role of follow-up CT.

PurposeOur aim was to evaluate the evolution of 20 patients with H1N1 pneumonia, focusing our attention on patients with severe clinical and radiological findings who developed post-acute respiratory distress syndrome (post-ARDS) pulmonary fibrosis.Materials and methodsTwenty adult patients (nine women and 11 men; mean age 43.5±16.4 years) with a diagnosis of H1N1 infection confirmed by pharyngeal swab came to our attention from September to November 2009 and were followed up until September 2010. All patients were hospitalised in consideration of the severity of clinical findings, and all underwent chest X-ray. Twelve of them underwent at least one computed tomography (CT) scan of the chest.ResultsIn 75% of cases (15/20), there was complete resolution of the clinical and radiological findings. Twenty-five percent of patients (5/20) developed acute respiratory distress syndrome (ARDS), which progressed to predominantly peripheral pulmonary fibrosis in 10% (2/20; one died and one had late-onset pulmonary fibrosis, documented on day 68). Moreover, in one patient with a CT diagnosis of pulmonary fibrosis, we observed progressive regression of radiological findings over 4 months of follow-up.ConclusionsIn patients with H1N1 pneumonia, post-ARDS pulmonary fibrosis is not a rare complication. Therefore, a CT scan should be performed in all patients with severe clinical findings. Our study demonstrated that in these patients, fibrosis could present a different spatial distribution and a different temporal trend, with delayed late onset; moreover, in one case, the signs of interstitial lung disease partially regressed over time. Therefore, CT should be considered not only in the diagnostic stage, but also during the follow-up.RiassuntoObiettivoScopo del presente lavoro è quello di effettuare una valutazione evolutiva in 20 pazienti con polmonite da H1N1, focalizzando l’attenzione sui casi con severo decorso clinico-radiologico e sulle sequele polmonari post-acute respiratory distress syndrome (ARDS).Materiali e metodiVenti pazienti adulti, di cui 9 donne e 11 uomini, con età media di 43,5±16,4 anni e con diagnosi di influenza suina H1N1 confermata mediante tampone faringeo sono giunti alla nostra osservazione tra settembre e novembre 2009 e sono stati valutati evolutivamente fino a settembre 2010. Tutti i pazienti, in considerazione della severità del quadro clinico, sono stati sottoposti a regime di ricovero ed hanno eseguito almeno una radiografia del torace; 12 di essi hanno eseguito inoltre almeno una tomografia computerizzata (TC) del torace.RisultatiNel 75% dei casi (15/20) la sintomatologia e le alterazioni a carico del parenchima polmonare sono regredite dopo terapia in assenza di significativi esiti parenchimali. Nel restante 25% (5/20), il ricovero è stato gravato da complicanze respiratorie fino ad un quadro conclamato di ARDS, con evoluzione in interstiziopatia prevalentemente periferica in 2 pazienti, di cui uno poi deceduto ed uno con sviluppo tardivo di fibrosi polmonare documentata in 68a giornata. Si segnala infine un caso in cui si è verificata comparsa di segni compatibili con interstiziopatia polmonare che sono andati incontro a graduale regressione nei controlli a quattro mesi.ConclusioniPoiché l’evoluzione in interstiziopatia polmonare dell’ARDS da H1N1 rappresenta una complicanza di non rara osservazione, il monitoraggio evolutivo dei pazienti con presentazioni cliniche particolarmente severe non può esimersi dall’impiego dell’indagine TC. Il nostro studio ha documentato che la interstiziopatia conseguente alla polmonite virale con ARDS può presentare non solo una distribuzione spaziale peculiare, ma anche un inconsueto andamento temporale, con insorgenza tardiva; inoltre, in un singolo caso si è documentata una parziale e graduale riduzione nel tempo dei segni di interstiziopatia. Questa osservazione può giustificare ulteriormente, l’impiego della TC non solo in acuto ma soprattutto nel monitoraggio tardivo di questi pazienti.

Screening for lung cancer using low-dose spiral CT: 10 years later, state of the art

Ten years after the first papers on this subject, this editorial represents a brief review on lung cancer screening with low-dose spiral CT. The aim is to present the main theoretical and practical problems related to lung cancer screening, the historical background and results of observational studies and the main ongoing randomised controlled trials. In particular, the National Lung Screening Trial (NLST), which was interrupted early, is discussed. The opinion of the authors is that too many questions are still awaiting an answer.RiassuntoA dieci anni dai primi lavori sull’argomento, questo editoriale fa il punto della situazione sullo screening del tumore polmonare mediante tomografia computerizzata (TC) a bassa dose. Vengono esposti i principali problemi teorici e pratici connessi alla screening oncologico per il tumore polmonare, le premesse storiche, i risultati degli studi osservazionali ed i principali trial randomizzati e controllati in corso. In particolare, viene trattato in dettaglio lo studio National Lung Screening Trial (NLST), che è stato concluso con anticipo. Vengono esposti i risultati, insieme alle molte questioni ancora irrisolte e alle domande che attendono una risposta.

The many faces of pulmonary metastases of osteosarcoma: Retrospective study on 283 lesions submitted to surgery

OBJECTIVE CT is the recommended technique for the detection of pulmonary metastases in patients affected by osteosarcoma, though claimed to show several limits compared to manual palpation. We retrospectively analyzed CT features of suspected lesions submitted to surgery to address its current accuracy and to investigate criteria for predicting histology. MATERIALS AND METHODS CT scans of 70 patients submitted to thoracotomy between 2007-2013 were reviewed. Overall, 123 thoracotomies were performed and 283 lesions seen on CT were resected. Shape, size, presence and type of calcification, evolution of each lesion were analyzed. Number and histology of nodules detected at thoracotomy were recorded and compared to CT data. RESULTS 234/283--82.7% Lesions were metastases; 143--61.1% were calcified; most metastases were nodular (201/234--85.9%), but in 33/234--14.1% other findings were detected (striae, consolidations, pleural plaques/masses, cavitations, ground glass opacities, irregular shapes, halo sign). Malignant lesions were more frequently calcified, larger, with progression over time--p<0.0001. Manual palpation identified 314 lesions, 248 metastatic--79.0%: CT missed 31/314--9.9% lesions, whereof 14/31--45.2% were metastases. CONCLUSIONS Though most lesions are nodular and calcified, up to 40% are not calcified and atypical findings are not uncommon (14.1%). The identification of the atypical radiological presentation of metastases could be the key for improving CT accuracy.

Evolution of the subsolid pulmonary nodule: a retrospective study in patients with different neoplastic diseases in a nonscreening clinical context

PurposeThe aims of this study were to evaluate the high-resolution computed tomography (HRCT) features of subsolid pulmonary nodules (SSN) detected in cancer patients to differentiate between benign and malignant lesions, to assess their evolution during the follow-up, and to determine which neoplastic diseases are most frequently associated with the growth in size and/or density of SSN.Materials and methodsNinety-seven patients with a total of 146 subsolid nodules [140 pure ground-glass opacities (pGGOs) and six mixed ground-glass opacities (mGGOs)] were retrospectively recruited. Two chest radiologists independently reviewed the HRCT features of the nodules (location, shape, size, density) and the patients’ clinical characteristics (sex, age, smoking and cancer history). Mean duration of follow-up was more than 2 years.ResultsDuring follow-up, 58% of SSN remained stable, 10% disappeared. An increase in size and/or density was seen in 32% of SSN, and in particular in partly solid (mGGOs), large (≥10 mm) and irregular nodules. The majority of small-size (<5 mm) rounded SSN remained stable. SSN growth was more frequent in patients with advanced age and a history of smoking, and occurred even after a long period of stability (39% of pGGOs “changed” over 3 years). The neoplastic diseases most frequently associated with SSN growth were cancers of lung (34%), breast (15%), colon (15%) and bladder (10%).ConclusionsThe observation of a sample of cancer patients has shown that SSN may frequently grow in size and/or density in these patients, especially if associated powith cancers of lung, breast, colon and bladder. As the majority of SSN showed a very slow development time, a follow-up period longer than 3 years is warranted even in cancer patients.RiassuntoObiettivoScopo del presente lavoro è valutare le caratteristiche alla tomogracfia computerizzata ad alta risoluzione (HRCT) dei noduli polmonari subsolidi (NSS) in pazienti oncologici, per differenziare NSS benigni e maligni, valutare la loro evoluzione durante il follow-up e determinare quali patologie neoplastiche più frequentemente si associano a crescita dimensionale e/o densitometrica delle lesioni.Materiali e metodiSono stati reclutati in maniera retrospettiva 97 pazienti, per un totale di 146 NSS (140 ground glass “puri” — pGGO, e 6 ground glass “misti” — mGGO). Le caratteristiche HRCT dei noduli (localizzazione, forma, dimensioni, densità) e quelle cliniche dei pazienti (sesso, età, abitudine al fumo e anamnesi oncologica) sono state valutate indipendentemente da due radiologi toracici. La durata media del follow-up è stata superiore ai 2 anni. Risultati. Durante il follow-up il 58% dei NSS è rimasto invariato, il 10% è scomparso, mentre in circa un terzo dei casi (32%) si è verificato un aumento di dimensioni e/o densità, specialmente in caso di noduli parzialmente solidi (mGGO), di grandi dimensioni (≥10 mm) e irregolari. La maggior parte dei NSS rotondeggianti e di piccole dimensioni (<5 mm) è rimasto invariato. La crescita è stata più frequente in soggetti di età avanzata e con storia di fumo e si è verificata anche dopo un lungo periodo di stabilità (39% di pGGO “modificati” oltre i 3 anni). Le patologie oncologiche più frequentemente associate a crescita dei NSS sono risultate i tumori del polmone (34%), della mammella (15%), del colon (15%) e della vescica (10%).ConclusioniL’osservazione di un campione di pazienti oncologici ha dimostrato come i NSS frequentemente possono crescere di dimensioni e/o densità in questi pazienti, soprattutto se associati a tumori del polmone, della mammella, del colon e della vescica. La maggioranza di essi ha mostrato un tempo di sviluppo estremamente lento, perciò, un follow-up superiore ai 3 anni appare giustificato anche nei pazienti oncologici.

Dual-Energy X-Ray Absorptiometry in the Evaluation of Abdominal Aortic Calcifications

The objective of this study was to evaluate the diagnostic performance of the new dual-energy X-ray absorptiometry equipment vs digital radiography (DR) in the detection and scoring of abdominal aortic calcifications (AACs). Seventy-five patients with indication for morphometric evaluation of the spine underwent vertebral fracture assessment (VFA) and spinal DR (gold standard). The radiographic and VFA images were analyzed to detect AAC using a previously validated 24-point scale (AAC-24) and a simplified 8-point scale (AAC-8). The evaluation was conducted by 2 expert radiologists and repeated by the more experienced of the 2 after 7d to verify the results. Patients with a score of 5 or more in AAC-24 and 3 or more in AAC-8 were considered at risk for cardiovascular diseases (CVDs). The aorta was not completely visible in 11 VFA and 1 DR images. DR detected AAC in 42 of the 63 patients (66.7%), whereas 15 patients (23.8%) were considered at risk for CVD. The VFA showed sensitivity, specificity, and accuracy in the detection of AAC with values of 78.6%, 85.7%, and 81.0%, respectively, with both AAC-24 and AAC-8; in the identification of patients at risk for CVD, VFA demonstrated sensitivity, specificity, and accuracy, respectively, with values of 86.7%, 100%, and 96.8% using AAC-24 and 86.7%, 93.8%, and 92.1% using AAC-8. In the detection of AAC, intraobserver agreement was superimposable using both the techniques (κ=1.00), whereas in the identification of patients at risk for CVD, kappa values were 0.96 and 0.95 using AAC-24 and 1.00 and 0.96 using AAC-8 for DR and VFA, respectively. Interobserver agreement in the evaluation of the presence/absence of AAC showed a kappa value of 0.76 for DR and 0.71 for VFA, whereas kappa values of 0.91 and 0.87 for DR and 0.85 and 0.83 for VFA were achieved for CVD risk using AAC-24 and AAC-8, respectively. AAC can be easily and accurately diagnosed by VFA with satisfactory accuracy, reproducibility, and repeatability. VFA may be used in the assessment and monitoring of AAC.

Integrated Use of Lung Ultrasound and Chest X-Ray in the Detection of Interstitial Lung Disease.

Background: Current data have shown that lung ultrasound (LUS) may be useful in the detection of interstitial lung disease (ILD) by the evaluation of B-lines, the sonographic marker of pulmonary interstitial syndrome. Nevertheless, no prospective study has compared LUS to chest X-ray (CXR) for ILD assessment, and there is no general agreement on the specific echographic diagnostic criteria for defining ILD. Objectives: The aims of this study were (1) to compare the accuracy of LUS and CXR in the detection of ILD using high-resolution CT (HRCT) as the gold standard and (2) to compare the accuracy of different echographic diagnostic criteria for ILD diagnosis. Methods: LUS was performed on 104 patients undergoing HRCT for suspected ILD. In 49 patients, a CXR scan performed within 3 months of HRCT was analyzed. ILD was defined as the presence of ≥5 B-lines in ≥3 chest areas. A total B-line score (TBLS) was also calculated, as in previous studies. The observers evaluating LUS and CXR were blinded to the HRCT results and clinical data. Results: On HRCT, ILD was assessed in 50 patients. CXR was specific (91%; 95% CI 80-100) but not sensitive (48%; 95% CI 28-67). Conversely, LUS showed high sensitivity (92%; 95% CI 84-99) and low specificity (79%; 95% CI 69-90). Using a TBLS, sensitivity did not change, while specificity decreased. Conclusions: LUS could be a sensitive tool for ILD detection. CXR and LUS have different but complementary features, and their combined use could reduce the need for HRCT. The use of different diagnostic criteria for defining ILD does not affect sensitivity but influences specificity.

Combined pulmonary fibrosis and emphysema (CPFE): what radiologist should know.

Combined pulmonary fibrosis and emphysema is a relatively newly defined entity, which has been deeply studied in the recent years. Despite the wide numbers of papers on this topic, there are still several open questions about pathogenesis, epidemiology, natural history and prognosis. The diagnosis could be assessed only after HRCT scan as functional tests often result in an underestimation of this syndrome. What radiologists need to know about this syndrome consists in the heterogeneity of appearances: emphysema is mainly paraseptal and fibrotic pattern could be variable, including the variant of airspace enlargement with fibrosis which needs to be differentiated from honeycombing. A special attention must be paid on complications which could worsen the prognosis, such as pulmonary hypertension and lung cancer. Further studies are needed to address if the type of fibrotic pattern as well as fibrosis CT index could be considered as prognostic factors. Thus, the role of radiologists in the management of these patients is crucial as it involves diagnosis, detection of complications and could possible concerns the identification of patients at higher risk.

Incidental finding of bronchial diverticula in a non-smoker population: evaluation on thin-section CT

Bronchial diverticula have been described as a common radiological finding in smoker patients with COPD, but the specificity of this sign should be further investigated. Thus, the aim of our study was to evaluate the prevalence of diverticula in a cohort of non-smoker subjects. Between February and July 2012, 2438 patients were admitted to our Radiology Unit to undergo a chest CT. Among them, we enrolled 121 non-smoking patients (78/121-64.5% females, 43/121-35.5% males), of different age (57.0±20.7 years-range: 12-88), without any respiratory symptoms, submitted to chest CT for several reasons (oncologic evaluation: 59/121-48.8%; follow up of lung nodules: 27/121-22.3%; screening in connectivitis: 12/121-9.9%; others: 23/121-19.0%). We considered thin-section CT scan on axial, coronal and sagittal plans to evaluate prevalence, numbers and level of bronchial diverticula. Diverticula were found in 41/121-33.9% patients, with a slight major prevalence in males (p=0.048), but no significant difference on age. In 31/41-75.6% the number was <3, whereof 17/31-54.8% with just one diverticulum assessed. Regarding the level, in 30/41-73.2% they were subcarinal, but they were also detected in mainstem (2/41-4.9%) and lobar bronchi (with the right upper lobe bronchus most frequently involved- 12/41-29.3%). Bronchial diverticula can be observed in non-smokers, as well as in smoker patients with COPD. However, their prevalence seems to be lower than in smokers and they tend to be isolated and subcarinal. The age of patients does not influence their finding. More studies should be proposed to better define a cut-off between smokers and healthy subjects.