Giovanni Barchetti

The Role of 3 Tesla Diffusion-Weighted Imaging in the Differential Diagnosis of Benign versus Malignant Cervical Lymph Nodes in Patients with Head and Neck Squamous Cell Carcinoma

Objective. The aim of this study was to validate the role of diffusion-weighted imaging (DWI) at 3 Tesla in the differential diagnosis between benign and malignant laterocervical lymph nodes in patients with head and neck squamous cell carcinoma (HNSCC). Materials and Methods. Before undergoing surgery, 80 patients, with biopsy proven HNSCC, underwent a magnetic resonance exam. Sensitivity (Se) and specificity (Spe) of conventional criteria and DWI in detecting laterocervical lymph node metastases were calculated. Histological results from neck dissection were used as standard of reference. Results. In the 239 histologically proven metastatic lymphadenopathies, the mean apparent diffusion coefficient (ADC) value was 0.903 × 10−3 mm2/sec. In the 412 pathologically confirmed benign lymph nodes, an average ADC value of 1.650 × 10−3 mm2/sec was found. For differentiating between benign versus metastatic lymph nodes, DWI showed Se of 97% and Spe of 93%, whereas morphological criteria displayed Se of 61% and Spe of 98%. DWI showed an area under the ROC curve (AUC) of 0.964, while morphological criteria displayed an AUC of 0.715. Conclusions. In a DWI negative neck for malignant lymph nodes, the planned dissection could be converted to a wait-and-scan policy, whereas DWI positive neck would support the decision to perform a neck dissection.

Metabolic atrophy and 3-T 1H-magnetic resonance spectroscopy correlation after radiation therapy for prostate cancer

To correlate 3‐T magnetic resonance spectroscopic imaging (MRSI) with prostate‐specific antigen (PSA) levels in patients with prostate cancer treated with external beam radiation therapy to assess the potential advantages of MRSI.

Negative Multiparametric Magnetic Resonance Imaging for Prostate Cancer: What's Next?

BACKGROUND Multiparametric magnetic resonance imaging (mpMRI) of the prostate has excellent sensitivity in detecting clinically significant prostate cancer (csPCa). Nevertheless, the clinical utility of negative mpMRI (nMRI) is less clear. OBJECTIVE To assess outcomes of men with nMRI and clinical follow-up after 7 yr of activity at a reference center. DESIGN, SETTING, AND PARTICIPANTS All mpMRI performed from January 2010 to May 2015 were reviewed. We selected all patients with nMRI and divided them in group A (naïve patients) and group B (previous negative biopsy). All patients without a diagnosis of PCa had a minimum follow-up of 2 yr and at least two consecutive nMRI. Patients with positive mpMRI were also identified to assess their biopsy outcomes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS A Kaplan-Meier analysis was performed to assess both any-grade PCa and csPCa diagnosis-free survival probabilities. Univariable and multivariable Cox regression models were fitted to identify predictors of csPCa diagnosis. RESULTS AND LIMITATIONS We identified 1545 men with nMRI, and 1255 of them satisfied the inclusion criteria; 659 belonged to group A and 596 to group B. Any-grade PCa and csPCa diagnosis-free survival probabilities after 2 yr of follow-up were 94% and 95%, respectively, in group A; in group B, they were 96%. After 48 mo of follow-up, any-grade PCa diagnosis-free survival probability was 84% in group A and 96% in group B (log rank p<0.001). Diagnosis-free survival probability for csPCa was unchanged after 48 mo of follow-up. On multivariable Cox regression analysis, increasing age (p=0.005) was an independent predictor of lower csPCa diagnosis probability, while increasing prostate-specific antigen (PSA) and PSA density (<0.001) independently predicted higher csPCa diagnosis probability. The prevalence of and positive predictive value for csPCa were 31.6% and 45.5%, respectively. Limitations include limited follow-up and the inability to calculate true csPCa prevalence in the study population. CONCLUSIONS mpMRI is highly reliable to exclude csPCa. Nevertheless, systematic biopsy should be recommended even after nMRI, especially in younger patients with high or raising PSA levels. PATIENT SUMMARY It is a matter of debate whether patients with negative multiparametric magnetic resonance imaging (mpMRI) of the prostate could obviate the need to perform a systematic biopsy. In this report, we looked at the outcomes of patients with negative mpMRI and midterm clinical follow-up at a reference center. We found mpMRI to be highly reliable to exclude significant prostate cancer; nonetheless, systematic biopsy must still be recommended after negative mpMRI in patients with high clinical suspicion of prostate cancer.

An evaluation of morphological and functional multi-parametric MRI sequences in classifying non-muscle and muscle invasive bladder cancer

ObjectivesOur goal is to determine the ability of multi-parametric magnetic resonance imaging (mpMRI) to differentiate muscle invasive bladder cancer (MIBC) from non-muscle invasive bladder cancer (NMIBC).MethodsPatients underwent mpMRI before tumour resection. Four MRI sets, i.e. T2-weighted (T2W) + perfusion-weighted imaging (PWI), T2W plus diffusion-weighted imaging (DWI), T2W + DWI + PWI, and T2W + DWI + PWI + dif-fusion tensor imaging (DTI) were interpreted qualitatively by two radiologists, blinded to histology results. PWI, DWI and DTI were also analysed quantitatively. Accuracy was determined using histopathology as the reference standard.ResultsA total of 82 tumours were analysed. Ninety-six percent of T1-labeled tumours by the T2W + DWI + PWI image set were confirmed to be NMIBC at histopathology. Overall accuracy of the complete mpMRI protocol was 94% in differentiating NMIBC from MIBC. PWI, DWI and DTI quantitative parameters were shown to be significantly different in cancerous versus non-cancerous areas within the bladder wall in T2-labelled lesions.ConclusionsMpMRI with DWI and DTI appears a reliable staging tool for bladder cancer. If our data are validated, then mpMRI could precede cystoscopic resection to allow a faster recognition of MIBC and accelerated treatment pathways.Key Points• A critical step in BCa staging is to differentiate NMIBC from MIBC.• Morphological and functional sequences are reliable techniques in differentiating NMIBC from MIBC.• Diffusion tensor imaging could be an additional tool in BCa staging.

Bilateral Adrenal Hemorrhage in a Patient with Myelodysplastic Syndrome: Value of MRI in the Differential Diagnosis

Bilateral adrenal hemorrhage is a rare potentially life-threatening event that occurs either in traumatic or nontraumatic conditions. The diagnosis is often complicated by its nonspecific presentation and its tendency to intervene in stressful critical illnesses. Due to many disorders in platelet function, hemorrhage is a major cause of morbidity and mortality in patients affected by myeloproliferative diseases. We report here the computed tomography and magnetic resonance imaging findings of a rare case of bilateral adrenal hemorrhage in a patient with myelodysplastic syndrome, emphasizing the importance of MRI in the differential diagnosis.

Imaging in Bladder Cancer: Can We Do Better?

Imaging studies are required for disease staging in muscle-invasive bladder cancer in order to evaluate the extent of local tumour invasion, the presence of tumour spread to lymph nodes and the presence of tumour spread to upper urinary tract and/or to other distant organs. Magnetic resonance (MRI) as has a higher accuracy compared to computed tomography CT for primary tumour staging thanks to its superior soft tissue contrast; however, CT remains the most commonly used imaging modality, due to its shorter acquisition time and lower susceptibility to variations related to patients’ characteristics. As regards to primary tumour detection, virtual cystoscopy has been developed with promising results. To determine the lymph node status of patients with muscle-invasive bladder cancer FDG PET/CT has been tested: it seems to provide advantages over CT and MRI in lymph node assessment, even if more evidences are required. Finally, but perhaps more importantly, MRI is currently deemed to be able to differentiate T1 from T2 tumors. As this step is the most important and often the most time- and resources-consuming, if MRI is demonstrated to be reliable in such differentiation, the first steps of the diagnostic process of bladder cancer may be changed.

State‐of‐the‐art imaging techniques in the management of preoperative staging and re‐staging of prostate cancer

We aimed to review the current state‐of‐the‐art imaging methods used for primary and secondary staging of prostate cancer, mainly focusing on multiparametric magnetic resonance imaging and positron‐emission tomography/computed tomography with new radiotracers. An expert panel of urologists, radiologists and nuclear medicine physicians with wide experience in prostate cancer led a PubMed/MEDLINE search for prospective, retrospective original research, systematic review, meta‐analyses and clinical guidelines for local and systemic staging of the primary tumor and recurrence disease after treatment. Despite magnetic resonance imaging having low sensitivity for microscopic extracapsular extension, it is now a mainstay of prostate cancer diagnosis and local staging, and is becoming a crucial tool in treatment planning. Cross‐sectional imaging for nodal staging, such as computed tomography and magnetic resonance imaging, is clinically useless even in high‐risk patients, but is still suggested by current clinical guidelines. Positron‐emission tomography/computed tomography with newer tracers has some advantage over conventional images, but is not cost‐effective. Bone scan and computed tomography are often useless in early biochemical relapse, when salvage treatments are potentially curative. New imaging modalities, such as prostate‐specific membrane antigen positron‐emission tomography/computed tomography and whole‐body magnetic resonance imaging, are showing promising results for early local and systemic detection. Newer imaging techniques, such as multiparametric magnetic resonance imaging, whole‐body magnetic resonance imaging and positron‐emission tomography/computed tomography with prostate‐specific membrane antigen, have the potential to fill the historical limitations of conventional imaging methods in some clinical situations of primary and secondary staging of prostate cancer.

Improvement of prostate cancer detection combining a computer-aided diagnostic system with TRUS-MRI targeted biopsy

PurposeTo validate a novel consensus method, called target-in-target, combining human analysis of mpMRI with automated CAD system analysis, with the aim to increasing the prostate cancer detection rate of targeted biopsies.MethodsA cohort of 420 patients was enrolled and 253 patients were rolled out, due to exclusion criteria. 167 patients, underwent diagnostic 3T MpMRI. Two expert radiologists evaluated the exams adopting PI-RADSv2 and CAD system. When a CAD target overlapped with a radiologic one, we performed the biopsy in the overlapping area which we defined as target-in-target. Targeted TRUS-MRI fusion biopsy was performed in 63 patients with a total of 212 targets. The MRI data of all targets were quantitatively analyzed, and diagnostic findings were compared to pathologist’s biopsy reports.ResultsCAD system diagnostic performance exhibited sensitivity and specificity scores of 55.2% and 74.1% [AUC = 0.63 (0.54 ÷ 0.71)] , respectively. Human readers achieved an AUC value, in ROC analysis, of 0.71 (0.63 ÷ 0.79). The target-in-target method provided a detection rate per targeted biopsy core of 81.8 % vs. a detection rate per targeted biopsy core of 68.6 % for pure PI-RADS based on target definitions. The higher per-core detection rate of the target-in-target approach was achieved irrespective of the presence of technical flaws and artifacts.ConclusionsA novel consensus method combining human reader evaluation with automated CAD system analysis of mpMRI to define prostate biopsy targets was shown to improve the detection rate per biopsy core of TRUS-MRI fusion biopsies. Results suggest that the combination of CAD system analysis and human reader evaluation is a winning strategy to improve targeted biopsy efficiency.

Diagnosis of pneumothorax without exposure to ionising radiation

A 14-year-old female patient affected by ataxia telangiectasia (AT) syndrome presented with mild dyspnoea and chest discomfort of a few days duration. After a short course of antibiotic therapy, which yielded no significant clinical improvement, a chest MRI was requested to evaluate possible acute or chronic pulmonary infections. The choice fell on MRI first because the patient’s conditions was not critical, and, second, to avoid further exposure to ionising radiations, as the patient had undergone a chest X-ray 2 weeks earlier for a similar episode. The MRI study unexpectedly revealed a spontaneous right-sided pneumothorax of moderate size (figure 1). The pneumothorax was successfully treated with a chest tube and the patient recovered …

Evaluation of early myocardial damage in systemic sclerosis (SSc): a cardiovascular magnetic resonance study

Background Cardiac involvement in systemic sclerosis (SSc) is mainly characterised by diffuse myocardial fibrosis and impairment of the microcirculation; even if clinically silent, it is increasingly recognized to be responsible for higher morbidity and mortality rate. Cardiovascular magnetic resonance (CMR) is the most accurate non-invasive method able to detect myocardial inflammation and fibrosis, even though traditional CMR techniques such as T2-weighted and late gadolinium enhancement (LGE) are inaccurate to assess diffuse myocardial disease. Our aim was to investigate diffuse cardiac damage and perfusion abnormalities in asymptomatic SSc patients without known cardiac disease, using newer non-invasive imaging technique, such as T1 mapping and extracellular volume fraction (ECV), in pre-clinical stage.