Gianpaolo Cornalba

In Vivo Evaluation of the Chemical Composition of Urinary Stones Using Dual-Energy CT

OBJECTIVE The purpose of this article is to evaluate in vivo the chemical composition of urinary stones using dual-source and dual-energy CT, with crystallography as the reference standard. MATERIALS AND METHODS Forty patients (mean [± SD] age, 49 ± 17 years) with known or suspected nephrolithiasis underwent unenhanced abdominal CT for urinary tract evaluation using a dual-energy technique (tube voltages, 140 and 80 kVp). For each stone 5 mm or larger in diameter, we evaluated the site, diameter, CT density, surface (smooth vs rough), and stone composition. Patients were treated with extracorporeal shock wave lithotripsy (n = 34), percutaneous nephrolithotomy (n = 4), or therapeutic ureterorenoscopy (n = 2). Collected stones underwent crystallography, and the agreement with the results of dual-energy CT was calculated with the Cohen kappa coefficient. The correlation among stone composition, diameter, and CT density was estimated using the Kruskal-Wallis test. RESULTS Thirty-one patients had a single stone and nine had multiple stones, for a total of 49 stones. Forty-five stones were in the kidneys, and four were in the ureters; 23 had a smooth surface and 26 had a rough surface. The mean stone diameter was 12 ± 6 mm; mean CT density was 783 ± 274 HU. According to crystallography, stone composition was as follows: 33 were calcium oxalate, seven were cystine, four were uric acid, and five were of mixed composition. Dual-energy CT failed to identify four stones with mixed composition, resulting in substantial agreement between dual-energy CT and crystallography (Cohen κ = 0.684). Stone composition was not correlated with either stone diameter (p = 0.920) or stone CT density (p = 0.185). CONCLUSION CT showed excellent accuracy in classifying urinary stone chemical composition, except for uric acid-hydroxyapatite mixed stones.

MRI in identifying hepatic steatosis in obese children and relation to ultrasonography and metabolic findings.

Objectives: The aim of this study was to identify nonalcoholic fatty liver in obese children by magnetic resonance imaging (MRI) and to compare the findings with the data from ultrasonography and from clinical and laboratory testing. Patients and Methods: Sixty obese children, 6 to 14 years old, underwent hepatic MRI and abdominal ultrasonography. Biochemistry determinations included serum aminotransferases, lipid profile, glucose, and insulin. Anthropometry included body mass index, total and trunk fat, and fat-free mass obtained by dual-energy radiographic absorptiometry. Hepatic steatosis, judged as hepatic fat fraction by MRI, was ≥9%. Results: By MRI, 14 (23%) children had hepatic steatosis; of those, 5 had a fat fraction of 9% to 18%, and 9 had a fat fraction >18%. At univariate analysis, fat fraction was positively associated with being male, serum alanine aminotransferase, aspartate aminotransferase, and γ-glutamyltransferase, body mass index z score, insulin, systolic pressure, and total and trunk fat mass. Hepatic steatosis was independently associated with alanine aminotransferase (P < 0.01). Overall, liver echogenicity on ultrasonography correlated well with fat fraction by MRI (correlation coefficient 0.527, P < 0.0001). Among the 27 children with increased liver echogenicity, 13 (48%) had hepatic fat fraction ≥9%, and 89% of children with echogenicity graded 2 or 3 had fat fraction >18%. All of the children (n = 9) with fat fraction >18% had increased liver echogenicity, and in 8 of them it was graded 2 or 3, but the MRI fat fraction ranged greatly (28%–45%). Conclusions: In obese children, nonalcoholic hepatic steatosis may be associated with the metabolic syndrome. Ultrasonography may be valuable in identifying high hepatic fat accumulation, but its ability to identify lower fat accumulation in the liver is scanty compared with MRI.

Liver fat change in obese children after a 1-year nutrition-behavior intervention.

Objectives: To evaluate whether a 1-year nutrition-behavior intervention based on normocaloric balanced diet and physical exercise may reduce liver fat in obese children. Patients and Methods: Twenty-six obese children (11 boys and 15 girls), aged 6 to 14 years, underwent anthropometric, nutritional, metabolic, and liver magnetic resonance imaging (MRI) examinations at baseline and after a 1-year nutrition-behavior intervention. Anthropometry included weight, height, waist and hip circumference, and total upper arm area. Body mass index z scores were calculated. Biochemistry included serum aminotransferases, lipid profile, glucose, and insulin. Liver steatosis was judged as hepatic fat fraction (FF) by MRI and was ≥9%. Results: Prevalence of steatosis was 34.6% at baseline and declined to 7.7% after intervention (P < 0.0001). Mean (95% CI) reduction of liver FF was 8.0% (4.0%–12.0%). In 77.8% of children with liver steatosis at baseline, the FF declined lower than 9% at the end of intervention, going from a mean (SD) of 18.7% (9.1) to 1.3% (4.1), (P < 0.0001). At the end of the intervention, children showed a mean reduction in body mass index z score of 0.26 (0.11–0.41) and waist circumference of 1.46 (0.34–2.60) cm. Triglycerides, total cholesterol, apolipoprotein A1, apolipoprotein B, ApoA1/ApoB ratio, and gamma-glutamyltransferase plasma values in plasma decreased at the end of intervention (P < 0.05). Conclusions: The results suggest that in obese children nutritional-behavior interventions may reduce the liver fat.

Malignant Incidental Extracardiac Findings on Cardiac CT: Systematic Review and Meta-Analysis

OBJECTIVE The objective of our study was to systematically review the evidence on incidental extracardiac findings on cardiac CT with a focus on previously unknown malignancies. MATERIALS AND METHODS A systematic search was performed (PubMed, EMBASE, Cochrane databases) for studies reporting incidental extracardiac findings on cardiac CT. Among 1099 articles initially found, 15 studies met the inclusion criteria. The references of those articles were hand-searched and 14 additional studies were identified. After review of the full text, 10 articles were excluded. Nineteen studies including 15,877 patients (64% male) were analyzed. A three-level analysis was performed to determine the prevalence of patients with incidental extracardiac findings, the prevalence of patients with major incidental extracardiac findings, and the prevalence of patients with a proven cancer. Heterogeneity was explored for multiple variables. Pooled prevalence and 95% CI were calculated. RESULTS The prevalence of both incidental extracardiac findings and major incidental extracardiac findings showed a high heterogeneity (I2>95%): The pooled prevalence was 44% (95% CI, 35-54%) and 16% (95% CI, 14-20%), respectively. No significant explanatory variables were found for using or not using contrast material, the size of the FOV, and study design (I2>85%). The pooled cancer prevalence for 10 studies including 5082 patients was 0.7% (95% CI, 0.5-1.0%), with an almost perfect homogeneity (I2<0.1%). Of 29 reported malignancies, 21 (72%) were lung cancers; three, thyroid cancers; two, breast cancers; two, liver cancers; and one, mediastinal lymphoma. CONCLUSION Although the prevalence of reported incidental extracardiac finding at cardiac CT was highly variable, a homogeneous prevalence of previously unknown malignancies was reported across the studies, for a pooled estimate of 0.7%; more than 70% of these previously unknown malignancies were lung cancers. Extracardiac findings on cardiac CT require careful evaluation and reporting.

Magnetic resonance imaging in the preoperative assessment of Mayer-Rokitansky-Kuster-Hauser syndrome

PurposeWe evaluated the accuracy of magnetic resonance imaging (MRI) in young women with primary amenorrhoea with suspected Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome (congenital absence of both vagina and uterus and presence of normal ovaries).Materials and methodsFifty-eight women (age range 14–30 years, mean 20.9) with primary amenorrhea were studied with MRI performed with a 1.0-T superconducting magnet (Philips NT Intera). All patients were examined in the supine position using a phased-array coil (four channels). Turbo spin-echo T2-weighted images were acquired in the sagittal, axial and coronal planes with the following parameters: TR 4,750–6,686, TE 100–120, FOV 350–375, 4- to 5-mm sections with a 0.4- to 0.5-mm intersection gap and NSA 6. T1-weighted images were acquired in the axial and coronal planes (TR 470, TE 15, FOV 350, 4-mm sections with a 0.6-mm intersection gap, NSA 3). Two experienced radiologists evaluated all the examinations in consensus to assess the presence, position and morphology of vagina, uterus, ovaries and kidneys and any pelvic abnormalities. MRI results were judged on the basis of laparoscopic findings in 41 patients.ResultsMRKH syndrome was confirmed in 56 patients with 100% sensitivity and specificity. MRI identified bilateral Müllerian buds in 34/56 (61%) and unilateral in 10/56 (18%) patients. MRI sensitivity was 81.42%, and there was good agreement with laparoscopy (k=0.55) and full agreement in the identification of cavitation between MRI and intraoperative sonography. Both ovaries were visualised in 54 patients, with regular morphology in 46 (82.1%), polycystic in 10 (17.8%), pelvic in 47 (83.6%) and extrapelvic in eight (14.5%). We found associated abnormalities of the upper urinary tract in six patients (solitary kidney in four and ptosis in two).ConclusionsMRI is a useful diagnostic tool in the preoperative evaluation of MRKH syndrome and is less expensive and invasive than laparoscopy. Strong cooperation between radiologists and surgeons is highly recommended.AbstractObiettivoValutare l’accuratezza della RM in donne con amenorrea primaria, con sospetta sindrome Mayer-Rokitansky-Kuster-Hauser (MRKH) (assenza congenita di vagina e utero con presenza di ovaie normali).Materiali e metodiCinquantotto donne (14–30 anni, media 20,9), con amenorrea primaria, sono state studiate con RM mediante magnete superconduttivo 1,0 T. Tutte le pazienti sono state esaminate in posizione supina con bobina multicanale (4 canali). Immagini turbo spin-echo T2 pesate sono state acquisite sui piani sagittale, assiale e coronale con i seguenti parametri: TR 4750–6686, TE 100–120, FOV 350–375, sezioni di 4–5 mm con interspazio di 0,4–0,5 mm i, NSA 6. Immagini T1 pesate sono state acquisite sui piani assiale e coronale (TR 470, TE 15, FOV 350, sezioni di 4 mm di spessore con interspazio di 0,6 mm, NSA 3). Due radiologi esperti hanno valutato gli esami in consenso per stabilire la presenza, sede e morfologia di vagina, utero, ovaie, reni ed eventuali ulteriori malformazioni pelviche. I risultati della RM sono stati confrontati con quelli laparoscopici in 41 pazienti.RisultatiLa sindrome MKRH è stata confermata in 56 pazienti con sensibilità e specificità del 100%. La RM ha identificato residui mülleriani in 34/56 (61%) e monolaterali in 10/56 (18%) pazienti. La sensibilità della RM è stata dell’81,42% e c’è stato un buon accordo con la laparoscopia (k Cohen 0,55) e un completo accordo nella identificazione delle cavitazione dei residui tra RM e ecografia intraoperatoria. Gli annessi bilaterali sono stati visualizzati in 54 pazienti, con regolare morfologia in 46 (82,1%), policistica in 10 (17,8%); sede pelvica in 47 (83,6%), extrapelvica in 8 (14,5%). Abbiamo riscontrato anomalie dell’apparato urinario superiore in 6 pazienti (monorene in 4, ptosico in 2).ConclusioniLa RM si è dimostrata utile metodica nella valutazione prechirurgica della sindrome MRKH ed è meno costosa ed invasive della laparoscopia. Una forte cooperazione tra radiologo e chirurgo è fortemente raccomandata.

Primary hyperparathyroidism: can ultrasonography be the only preoperative diagnostic procedure?

PurposeThe purpose of our study was to assess the role of ultrasonography (US) before surgical treatment of primary hyperparathyroidism.Materials and methodsWe retrospectively evaluated 77 patients (60 women, 17 men; mean age 59 years) with primary hyperparathyroidism who underwent parathyroid US prior to surgery. Sixty-five of 77 (84%) patients had undergone 99mTc- sestamibi (MIBI) scintigraphy. The results were correlated with the surgical and histopathological findings.ResultsSurgery revealed 85 abnormal parathyroid glands in 77 patients (70 adenomas, 15 hyperplasias). The locations of the parathyroid glands were typical cervical (n=77), thyrothymic ligament (n=3), carotid sheath (n=2), and mediastinum (n=3). In two patients, intrathyroid microadenoma was diagnosed by histopathology. Seventyfour enlarged glands in 64 patients were correctly identified at US. Per-patient sensitivity and positive predictive values, respectively, were 84% (64/76) and 99% (64/65) for US, 68% (44/65) and 100% (44/44) for scintigraphy and 91% (59/65) and 98% (59/60) for both techniques combined. We weighed 63 out of 85 glands, obtaining a value of 1,004±1,564 mg; 460 mg (mean±standard deviation; median).ConclusionsPreoperative detection and localisation of enlarged parathyroid glands can be based on US, an inexpensive and widely available method, limiting the use of scintigraphy to those cases with negative and/or doubtful findings on US.RiassuntoObiettivoScopo dello studio è stato valutare il ruolo dell’ecografia eseguita prima del trattamento chirurgico dell’iperparatiroidismo primario.Materiali e metodiSono stati valutati 77 pazienti (60 femmine; età media 59 anni) con iperparatiroidismo primario, studiati con ecografia e successivamente paratiroidectomizzati. Nell’84% dei pazienti (65/77) era stata eseguita una scintigrafia con 99mTc-sestamibi (MIBI). I risultati sono stati correlati con quelli dell’intervento e dell’esame istologico.RisultatiAll’intervento sono state riscontrate 85 paratiroidi anormali nei 77 pazienti (70 adenomi, 15 iperplasie). La sede di tali paratiroidi ingrandite, correttamente identificata dall’ecografia per 74 paratiroidi in 64 pazienti, era: cervicale tipica (n=77), legamento tireotimico (n=3), ricorrenziale (n=2), mediastino (n=3). In due pazienti è stato identificato un microadenoma intratiroideo all’esame istologico. Sensibilità e valore predittivo positivo, per paziente, sono risultati 84% (64/76) e 99% (64/65) per l’ecografia, 68% (44/65) e 100% (44/44) per la scintigrafia e 91% (59/65) e 98% (59/60) per le due metodiche combinate, rispettivamente. Il peso, disponibile per 63 delle 85 paratiroidi asportate, è risultato 1004±1564 mg; 460 mg (media±deviazione standard; mediana).ConclusioniL’identificazione e la localizzazione preoperatoria di paratiroidi ingrandite possono basarsi sull’ecografia, metodica assai diffusa e con costi contenuti, limitando l’utilizzo della scintigrafia ai casi negativi e/o dubbi all’ecografia.

[Bronchial and nonbronchial systemic artery embolization in managing haemoptysis: 31 years of experience].

PurposeThe authors report on 31 years of experience with bronchial (BAE) and/or nonbronchial (NBAE) systemic artery embolisation for managing haemoptysis.Materials and methodsA total of 534 patients who underwent bronchial artery angiography for haemoptysis between 1979 and 2010 were retrospectively evaluated. Of these patients, 477 (89%) had active bleeding and underwent BAE and/or NBAE (295 males and 182 females, aged between 12 and 71 years). Embolisation techniques, materials, major and minor complications and relapses were recorded.ResultsComplete resolution of haemoptysis was achieved within 24 h in 458/477 (96%) cases and within 48 h in 2% of cases. The aetiology of haemoptysis was as follows: cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD) (6%) and no apparent cause (21%). Major complications were recorded in 3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and transient quadriplegia (n=1). Minor complications were recorded in 143/477 (30%): chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8–36) months, haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%).ConclusionsBAE and NBAE are effective and safe for acute treatment of haemoptysis, with low recurrence and complication rates. Interventional radiologist experience is crucial to the successful haemoptysis control and preventing complications.RiassuntoObiettivoScopo del nostro lavoro è riportare l’esperienza di 31 anni nell’embolizzazione delle arterie bronchiali (BAE) e/o sistemiche non bronchiali (NBAE) nel controllo dell’emottisi.Materiali e metodiDal 1979 al 2010, 534 pazienti sottoposti ad angiografia delle arterie bronchiali per emottisi sono stati retrospettivamente valutati; 477 (89%) avevano sanguinamento attivo e hanno eseguito BAE e/o NBAE (295 maschi e 182 femmine, etá compresa tra 12 e 71 anni). Sono state riportate tecniche di embolizzazione, materiali impiegati, complicanze maggiori e minori e recidive.RisultatiQuattrocentocinquantotto/477 (96%) dei casi presentarono risoluzione completa dell’emottisi entro 24 ore, 2% entro 48 ore. L’eziologia dell’emottisi è stata fibrosi cistica (23%), bronchiectasie (13%), esiti tubercolari (8%), broncopneumopatia cronica ostruttiva (BPCO) (6%) e sine materia (21%). Tre/477 (0,6%) pazienti presentarono complicanze maggiori: ictus cerebrale (1), attacco ischemico transiente (TIA) (1) e tetraparesi transitoria (1); 143/477 (30%) presentarono complicanze minori: dolore toracico 86/143 (60%) e disfagia 29/143 (20%). Il follow-up medio fu di 14 mesi (8–36 mesi), recidiva di emottisi nella fibrosi cistica 42/110 (38%) e nelle altre patologie 77/367 (21%).ConclusioniLa BAE e NBAE sono tecniche efficaci e sicure nel trattamento acuto dell’emottisi, con bassa percentuale di recidive e complicanze. L’esperienza del radiologo interventista è un fattore molto importante nel successo del controllo dell’emottisi e nella prevenzione delle complicanze.Obiettivo Scopo del nostro lavoro e riportare l’esperienza di 31 anni nell’embolizzazione delle arterie bronchiali (BAE) e/o sistemiche non bronchiali (NBAE) nel controllo dell’emottisi.

Low-fat Angiomyolipoma of the Liver Studied with Contrast-Enhanced Ultrasound and Multidetector Computed Tomography

We report the case of a 30-year-old woman with persistent pain at the right hypochondrium, relapsing fever, and normal serum tests. Ultrasound showed a hyperechoic inhomogeneous mass; following sulfur hexafluoride injection, uniform enhancement at 14–16 s and rapid wash-out at 26 s was found. Multidetector computed tomography showed an inhomogeneously hypodense mass, with no detectable negative density values, characterized by inhomogeneous enhancement at the arterial phase and wash-out at the portal phase. Histopathology demonstrated a hepithelioid angiomyolipoma with a poor fatty component. This diagnosis should always be considered in the presence of a very rapid wash-out after intravenous contrast injection. However, a hepatocellular carcinoma cannot be excluded and the final diagnosis of low-fat angiomyolipoma must be pathologically proved based on immunohistochemistry.

Vascular Map Combined with CT Colonography for Evaluating Candidates for Laparoscopic Colorectal Surgery

Contrast-enhanced computed tomography colonography (CE-CTC) is a useful guide for the laparoscopic surgeon to avoid incorrectly removing the colonic segment and the failure to diagnose of synchronous colonic and extra-colonic lesions. Lymph node dissection and vessel ligation under a laparoscopic approach can be time-consuming and can damage vessels and organs. Moreover, mesenteric vessels have extreme variations in terms of their courses and numbers. We describe the benefit of using an abdominal vascular map created by CE-CTC in laparoscopic colorectal surgery candidates. We describe patients with different diseases (colorectal cancer, diverticular disease, and inflammatory bowel disease) who underwent CE-CTC just prior to laparoscopic surgery.

Radiofrequency ablation of pulmonary lesions

Purpose.Radiofrequency ablation uses the thermal energy produced by a generator to create a coagulative necrosis. The method is well established for the treatment of a variety of primary and secondary cancers of the liver but is less well studied for the treatment of lung malignancies.Materials and methods.From March 2005 to March 2006, 11 patients (seven men and four women) with single or multiple pulmonary nodules underwent radiofrequency ablation of 12 unresectable pulmonary tumours. Follow-up computed tomography (CT) was performed at 1, 3, 6, and 12 months after radiofrequency ablation. Lesions were evaluated for dimensions and contrast enhancement.Results.Radiofrequency ablation was well tolerated by all patients. Postprocedural complications included four cases of pneumothorax treated with simple aspiration without tube placement and one case of small parenchymal haemorrhage. There were no major complications.Conclusions.Radiofrequency ablation of primary or secondary pulmonary lesions is a safe and technically feasible option for the management of unresectable pulmonary malignancies.