Giovanni Pompili

Contrast radiology, computed tomography and ultrasonography in detecting internal fistulas and intra-abdominal abscesses in Crohn’s disease: a prospective comparative study

OBJECTIVES:Accurate assessment of intestinal complications of Crohns disease (CD) is extremely important, both in clinical practice and in trials. The accuracy of radiographic and ultrasonographic diagnosis of internal fistulae and abscesses complicating CD is still debated and requires further investigation. We compared ultrasonography (US) and contrast radiography in detecting intestinal fistulae and abscesses complicating CD.METHODS:A prospective study was carried out on 625 consecutive CD patients who underwent complete evaluation of the intestinal tract by means of colonoscopy and double contrast barium enema, small bowel enteroclysis, and abdominal ultrasound (US). Computed tomography (CT) was also carried out in cases of severe CD with clinical suspicion of septic complications. The accuracy of US, barium radiology, and CT in detecting internal fistulae and abscesses was assessed by comparing results with intraoperative findings in 128 consecutive patients who underwent operation immediately after diagnostic workup.RESULTS:Internal fistulae and intra-abdominal abscesses were identified intraoperatively in 56 (43.7%) and 26 (20.3%) patients, respectively. Diagnostic accuracy of US and x-ray studies in detecting internal fistulae was comparable (85.2% vs 84.8%), with sensitivity of 71.4% for US and 69.6% for x-ray studies, and specificity of 95.8% for both. Combination of radiographic techniques and US significantly improved diagnostic accuracy in detection of internal fistulae. In severe cases of CD with clinical suspicion of septic complications such as abdominal mass or fever, the accuracy of US, barium studies, and CT was 88.5%, 80.3%, and 77%, respectively (p = ns). The presence of abscesses was correctly detected in 90.9% of cases by means of US and in 86.4% by CT (p = ns), although accuracy was higher for CT (91.8%) than for US (86.9%) because of false positive results in US studies.CONCLUSION:Despite the fact that barium radiology is widely considered the method of choice in detection of internal fistulae, accuracy is not entirely satisfactory. Comparable accuracy was found for US and CT. The combination of barium and US studies, or the sole use of US in more CD patients with more severe disease, can reliably detect most internal fistulae and abscesses.

Endoscopic ultrasonography and magnetic resonance in preoperative staging of rectal cancer: Comparison with histologic findings

The development of new surgical techniques and use of neoadjuvant therapy have increased the need for accurate preoperative staging of rectal cancer. We compared the ability of endoscopic ultrasonography (EUS) and two magnetic resonance imaging (MRI) coils to locally stage rectal carcinoma before surgery. Forty-nine patients with histologically proven rectal carcinoma were T and N staged by EUS and either body coil MRI or phased-array coil MRI. After radical surgery, the preoperative findings were compared with histologic findings on the surgical specimen. For T stage, accuracies were 70% for EUS, 43% for body coil MRI, and 71% for phased-array coil MRI. For N stage, accuracies were 63% for EUS, 64% for body coil MRI, and 76% for phased-array coil MRI. For T stage, EUS had the best sensitivity (80%) and the same specificity (67%) as phased-array coil MRI. For N stage, phased-array coil MRI had the best sensitivity (63%) and the same specificity (80%) as the other methods. EUS and phased-array coil MRI provided similar results for assessing T stage. No method provided satisfactory assessments of local N stage, although phased-array coil MRI was marginally better in assessing this important parameter. Although none of the results differed significantly, phased-array coil MRI seems to be the best single method for the preoperative staging of rectal cancer.

Role of magnetic resonance imaging in evaluation of the activity of perianal Crohn's disease.

AIM To evaluate the diagnostic ability of contrast-enhanced Magnetic Resonance Imaging (MRI) in assessment of the activity of perianal fistulas in Crohns disease (CD) patients, compared to clinical data. MATERIALS AND METHODS Fifty CD patients (25 men; mean[SD] age: 40.4[12.6] years) with known or suspected perianal fistulas underwent perianal space MRI. Radiological activity of disease was measured as the percentage increase (PI) of ROI values of fistulas in relation to ROI values of healthy local fat, after contrast administration. Clinical activity of disease was defined according to Perianal Disease Activity Index (PDAI) and Fistula Drainage Assessment (FDA). RESULTS Forty-two patients presented perianal disease at MRI (55 fistulas identified). An association between both fistulas PI and PDAI (Pearsons coefficient 0.512, p<0.0001) and between PI and FDA (p=0.003) was demonstrated. Areas under ROC curves of PI values in relation to PDAI and FDA were respectively 0.876 [95%CI=(0.743-1.00), p<0.001] and 0.784 [95%CI=(0.588-0.980), p=0.003]. A cut-off value of PI, calculated on these preliminary data, correctly classified more than 90% of fistulas. CONCLUSIONS Contrast-enhanced MRI with PI calculation offered practical information about activity of perianal fistulas and might be helpful in providing a comprehensive evaluation of CD perianal disease.

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.

Myocardial Fatty Foci in Adult Patients with Tuberous Sclerosis Complex: Association with Gene Mutation and Multiorgan Involvement

PURPOSE To estimate the association between myocardial fatty foci (MFF) on chest computed tomographic (CT) images and type of gene mutation or multiorgan involvement in patients with tuberous sclerosis complex (TSC). MATERIALS AND METHODS This retrospective case-control study was approved by the ethics committee, which waived the need for patient consent. Forty-eight patients with definite TSC (41 women; mean age, 35 years ± 11 [standard deviation]) and 96 age- and sex-matched patients without TSC who had undergone chest CT were evaluated. Two blinded readers independently scored MFF as low-attenuation areas within the myocardium. Patient history, gene mutation, and multiorgan involvement were obtained from clinical records. Cohen κ, Mann-Whitney U, χ(2) or Fisher exact, Kruskal-Wallis, and Spearman statistics were calculated. RESULTS One or more MFF was detected in 50% (24 of 48) of patients with TSC; however, no MFF was detected in control patients (P < .001). MFFs were oval (62%, 15 of 24) or linear (38%, nine of 24) and involved the left ventricle in 13 patients and both ventricles in 24 patients (mostly the apical or midleft ventricle); median size was 127 mm(2). After four patients with TSC and unknown mutational status (two with MFF) were excluded, MFF was detected in 53% (10 of 19) of patients with TSC1 mutation, 65% (11 of 17) of patients with TSC2 mutation, and 12% (one of eight) of patients with TSC but without an identified mutation (P = .044). MFF presence was associated with brain (P = .011) and multiorgan (P = .008) involvement. The number of MFF per patient correlated with the degree of multiorgan involvement (P = .014). With MFF considered predictive of TSC, 50% (24of 48) sensitivity, 100% (96 of 96) specificity, 100% (24 of 24) positive predictive value, and 80% (96 of 120) negative predictive value were obtained. CONCLUSION MFF was highly specific for TSC. MFF presence was associated with TSC gene mutations and with brain or multiorgan involvement; their number per patient was correlated with the degree of multiorgan involvement.

Magnetic resonance imaging of renal involvement in genetically studied patients with tuberous sclerosis complex

PURPOSE To evaluate renal involvement in tuberous sclerosis complex (TSC). MATERIALS AND METHODS A series of 24 TSC patients (19 with genetically demonstrated disease), underwent abdominal 1.0-T MR imaging with axial/coronal T1- and T2-weighted scans, with/without fat saturation. We looked for angiomyolipomas (AMLs) and cysts in 47 kidneys of 24 patients. We evaluated the percentage of parenchymal involvement by manual contouring on the coronal scans in 39 kidneys of 20 patients. RESULTS We detected AMLs in 15/24 (63%) patients and in 27/47 (57%) kidneys, cysts in 14/24 (58%) and in 26/47 (55%); respectively. AMLs were found in 2/4 TSC1 and in 11/15 TSC2 patients, cysts were found in 2/4 TSC1 and in 9/15 TSC2 patients. The global renal involvement ranged from 0 to 32% (median, 18%) in TSC1 and from 0 to 100% (median, 39%) in TSC2 patients. A fair correlation (r=.464) was found between patients age and renal involvement, a good correlation (r=0.655) between renal involvement and creatinine clearance. CONCLUSION Renal parenchyma of TSC patients can be evaluated with MR imaging. A detectable renal involvement was found in 83% of patients, higher in TSC2 than in TSC1. Renal function seems to correlate with renal involvement quantified with MR imaging.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

Background and Aim: The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal. Methods: Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment. Results: In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn’t change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn’t change significantly. Conclusions: Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It’s not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree. (www.actabiomedica.it)

Use of ultrasound malignancy score (TMS) in the management of thyroid nodules

Purpose The purpose of this study was to validate the role of the total malignancy score (TMS) in identifying thyroid nodules suspicious for malignancy through the sum of their ultrasound features. Methods The local ethical committee approved this prospective observational study. We examined 231 nodules in 231 consecutive patients (164 females and 67 males; age range, 20 to 87 years; median age, 59 years; interquartile range, 48 to 70 years) who underwent ultrasound followed by fine-needle aspiration cytology (FNAC). The nodules were further classified using the TMS, which considers ultrasound features (number, echogenicity, structure, halo, margins, Doppler signal, calcifications, and growth), and the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), which considers cytological features. Patients with non-negative nodules (TBSRTC categories III to VI) underwent histological analysis, repeated FNAC, or 2 years of regular ultrasound follow-up. The associations between the final diagnosis, each of the ultrasound features, and the TMS were estimated using the chi-square test, the Mann-Whitney U test, and multivariate logistic regression. A receiver operating characteristic (ROC) curve was used to evaluate the diagnostic accuracy of the TMS. Results On ultrasound, 47% of the nodules (108 of 231) had a TMS <3, 18% (42 of 231) had a TMS of 3, and 35% (81 of 231) had a TMS >3. The FNAC results of 85% of the nodules (196 of 231) were benign, while 15% (35 of 231) had non-negative results. Hypoechogenicity, solid structure, the presence of microcalcifications, and the number of nodules were independent predictors of the final diagnosis, and the diagnostic accuracy of the TMS was good (area under the ROC curve, 0.82). Conclusion The TMS system is simple to use, reliable, easily reproducible, and closely reflects malignancy risk. Based on our results, FNAC could be limited to nodules with a TMS ≥3 without missing any cases of carcinoma.

Cooled tip radiofrequency ablation of benign thyroid nodules: preliminary experience with two different devices

Background Thyroid nodules are very common in general population. Even if benign, they may require a treatment in case of symptoms or cosmetic concerns. In the last years, minimally invasive treatments alternative to surgery have been developed, in particular ultrasound (US) guided radiofrequency ablation (RFA). Methods Twenty-four patients (9 males; 15 females; mean age 57.9 years) were treated and divided in two groups (A and B) according to the RFA needle used (18 gauge needle, AMICA; 17 gauge needle, COVIDIEN). Nodules and patients characteristics, together with procedural data were registered pre-treatment and at 1-month follow-up. US visibility of the needle, volume of the nodules, symptoms and cosmetic concerns, complications were registered. Results Visibility of the needle was not significantly different in the two groups (P=0.0787). At 1 month the mean volume of the nodules dropped from 37.1 to 25 mL in group A and from 23.2 to 15.4 mL in group B; shrinkage rate (36.9% and 39.5%, respectively) was not significantly different (P=0.3137). Symptoms decreased from 3.1 to 1.4 in group A and from 4 to 1.6 in group B: no significant differences in reductions were observed (P=0.3305). Cosmetic score decreased from 3.7 to 3.4 in group A and from 3.9 to 3.6 in group B: no significant differences in reductions were observed (P=0.96). Total complication rate (18.2% in group A vs. 23.1% in group B) did not showed significant differences (P=0.5049). Conclusions The two systems used in our study resulted equivalent in terms of US needle visibility, efficacy, symptom/cosmetic relief, safety. More patients and a longer follow-up are necessary to confirm our results.