Linda Calistri

Head and neck effective dose and quantitative assessment of image quality: a study to compare cone beam CT and multislice spiral CT

OBJECTIVES To evaluate the effective dose and image quality of horizontal CBCT in comparison with multislice spiral CT (MSCT) in scans of the head, cervical spine, ear and dental arches. METHODS A head and neck Alderson-Rando® phantom (The Phantom Laboratory, Salem, NY) equipped with 74 thermoluminescence dosemeters was exposed according to 5 different scans in CBCT and 4 different scans in MSCT. Spatial and contrast resolutions, in terms of modulation transfer function and contrast-to-noise ratio (CNR), were measured to obtain a quantitative assessment of image quality. RESULTS The CBCT effective dose was 248, 249, 361, 565 and 688 µSv in the cervical spine, head, ear, dental arches with small field of view and dental arches with medium field of view, respectively. The MSCT effective dose was 3409, 1892, 660 and 812 µSv in the cervical spine, head, ear and dental arches, respectively. The modulation transfer function was 0.895 vs 0.347, 0.895 vs 0.275, 0.875 vs 0.342 and 0.961 vs 0.352 for CBCT vs MSCT in the cervical spine, head, ear and dental arches, respectively. Head and cervical spine MSCT showed greater CNR than CBCT, whereas CNR of the ear and dental arches showed comparable values. CONCLUSIONS CBCT was preferable to MSCT for the ear and dental arches volumetric imaging due to its lower radiation dose and significantly higher spatial resolution. In the case of cervical spine and head imaging, MSCT should be generally recommended if a high contrast resolution is required, despite the greater radiation exposure.

Focal Liver Lesions Classification and Characterization: What Value Do DWI and ADC Have?

Objective The aim of this work was to analyze the value of diffusion-weighted imaging (DWI) in the classification/characterization of focal liver lesions (FLLs). Methods Retrospective study, approved by ethical board, of 100 proven FLLs (20 hemangiomas, 20 focal nodular hyperplasia, 20 dysplastic nodules, 20 hepatocellular carcinomas, and 20 metastases) was performed by 1.5-T MR. For each lesion, 2 readers, blinded of medical history, have evaluated 6 sets of images: set A (T1/T2-weighted images), set B (set A + DWI), set C (set B + apparent diffusion coefficient [ADC] map), set D (set A + dynamic and hepatobiliary phases), set E (set D + DWI), set F (set E + ADC map). Results In unenhanced images, the evaluation of the ADC improves the accuracy in classification/characterization (+9%/14%, respectively), whereas in enhanced images the accuracy was increased by DWI (+7%/12%, respectively) and ADC (+13%/19%, respectively). Diffusion-weighted imaging does not improve classification/characterization of hemangiomas, may be useful in focal nodular hyperplasia/dysplastic nodules vs metastases/hepatocellular carcinoma differentiation, and increases the classification/characterization of metastases in both unenhanced and enhanced images. Conclusions Diffusion-weighted imaging may improve classification/characterization of FLLs at unenhanced/enhanced examinations.

Role of cone-beam computed tomography with a large field of view in Goldenhar syndrome

Introduction Goldenhar syndrome is a rare disease with hemifacial microsomia and craniofacial disorders originating from the first and second branchial arches, such as ocular, auricular, and vertebral anomalies. The complexity and variety of the ways in which the disease presents itself usually need several examinations. In this study, we aimed to evaluate both craniofacial and vertebral skeletal anomalies and asymmetries between the nonaffected and affected sides in patients with Goldenhar syndrome by using cone‐beam computed tomography. Methods Ten patients (7‐14 years old; 6 boys, 4 girls) were evaluated via NewTom 5G cone‐beam computed tomography (QR srl, Verona, Italy) with a large field of view (18 × 16 cm). Ten anatomic facial landmarks were identified to measure the following distances bilaterally: sella turcica (ST)‐mandibular angle, ST‐condyle, ST‐mastoid, ST‐mental foramen, ST‐fronto zygomatic suture, ST‐zygomatic temporal suture, ST‐zygomatic facial foramen, ST‐sphenopalatine fossa, mandibular angle‐mandibular symphysis, and mandibular angle‐condyle. The following 6 volumes were calculated bilaterally: orbit, maxillary sinus, condyle, external ear canal, middle ear, and internal auditory canal. These measurements were performed to assess skeletal asymmetries to compare the nonaffected side with the affected side by the Wilcoxon test. Cervical spine anomalies were classified into fusion anomalies and posterior arch deficiencies. Results All patients showed a deficit of skeletal development on the affected side. Statistically significant differences (0.001 ≤ P value ≤ 0.043) between the nonaffected and affected sides were recorded for all measurements, except for ST‐frontozygomatic suture, mandibular angle‐mandibular symphysis, and maxillary sinus volume. Vertebral fusion anomalies and posterior arch deficiencies were found in 7 and 4 patients, respectively. Conclusions Cone‐beam computed tomography with a large field of view was able to accurately identify craniofacial and vertebral skeletal anomalies, and to quantify asymmetries between the nonaffected and affected sides for an efficient maxillofacial treatment planning. HighlightsGoldenhar syndrome is a rare disease characterized by craniofacial disorders.Patients are very young when they need several examinations and treatment planning.Head and neck multislice spiral computed tomography is usually avoided for radio‐protection reasons.CBCT can exactly identify craniofacial and vertebral skeletal anomalies at 1 time.CBCT could become the elective imaging technique for patients with Goldenhar syndrome.

Repetition of examination due to motion artifacts in horizontal cone beam CT: Comparison among three different kinds of head support

Aims and Objectives: The aim of this study was to evaluate the repetition rate of examination due to motion artifacts in horizontal cone beam computed tomography, using three different kinds of head support, with reference to the patients age. Further purpose was to evaluate how comfortable head supports were. Materials and Methods: Seven hundred and fifty patients underwent a maxillofacial/dental arches volumetric imaging scan. They were divided into three groups depending on the head support used: foam headrest, foam headrest with head strap, and head restraint helmet. Each group was subdivided into three age groups: ≤18-year-old, 19–65-year-old, and ≥66-year-old patients. A severity index of motion artifacts, divided into four tiers from absence to remarkable artifacts, was adopted. Finally, each patient gave their judgment about the head support comfort by a questionnaire including ten yes/no questions. A three-score scale (insufficient, sufficient, and good) was used to judge the comfort. Collected data were analyzed using the SPSS® version 23.0 statistical analysis software. Results: Forty-one patients (5.4%) repeated the examination. In 16 (2.1%), 15 (2.0%), and 10 (1.3%) of them, foam headrest, foam headrest with head strap, and head restraint helmet were used, respectively. Examination was repeated in 5.3%, 3.8%, and 10.6% in ≤18-year-old, 19–65-year-old, and ≥66-year-old patients, respectively. Patients almost always judged good the comfort for each kind of support. The lowest percentage of satisfaction was observed for the headrest with head strap and was judged good in 78% of the cases. Conclusions: The repetition rate of examination showed similar values among the foam headrest, foam headrest with head strap, and head restraint helmet in under 66-year-old patients. In over 65-year-old patients, the head restraint helmet obviously decreased the repetition rate of examination. All three head supports were good comfort, especially the foam headrest.

Is Panoramic Radiography an Accurate Imaging Technique for the Detection of Endodontically Treated Asymptomatic Apical Periodontitis

Introduction This study aimed to evaluate the diagnostic accuracy of panoramic radiography (PAN) for the detection of clinically/surgically confirmed apical periodontitis (AP) in root canal–treated teeth using cone‐beam computed tomographic (CBCT) imaging as the reference standard. Methods Two hundred forty patients with endodontically treated AP (diseased group) were detected via CBCT imaging using the periapical index system. They were divided into groups of 20 each according to lesion size (2–4.5 mm and 4.6–7 mm) and anatomic area (incisor, canine/premolar, and molar) in both the upper and lower arches. Another 240 patients with root filling and a healthy periapex (healthy group) were selected. All diseased and healthy patients underwent PAN first and a CBCT scan within 40 days. The periapical index system was also used to assess AP using PAN. Sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value for PAN images with respect to CBCT imaging were analyzed. The k value was calculated to assess both the interobserver reliability for PAN and the agreement between PAN and CBCT. Results PAN showed low sensitivity (48.8), mediocre negative predictive value (64.7), good diagnostic accuracy (71.3), and high positive predictive value (88.6) and specificity (93.8). Both interobserver reliability for PAN and agreement between PAN and CBCT were moderate (k = 0.58 and 0.42, respectively). The best identified AP was located in the lower canine/premolar and molar areas, whereas the worst identified AP was located in the upper/lower incisor area and upper molar area. Conclusions PAN showed good diagnostic accuracy, high specificity, and low sensitivity for the detection of endodontically treated AP.

Cardiac magnetic resonance in patients with mitral valve prolapse: Focus on late gadolinium enhancement and T1 mapping

ObjectivesTo evaluate the incidence of late-gadolinium-enhancement (LGE) in mitral valve prolapse (MVP) (in the absence of other heart/valvular diseases), and its association with the degree of mitral regurgitation (MR) and/or with complex ventricular arrhythmia (ComVA), and to analyse the role of T1 mapping in the evaluation of MVP patients.MethodsWe included all consecutive patients with MVP who underwent during 2015–2016 a comprehensive cardiac magnetic resonance (CMR) examination at 1.5 T. We evaluated the association of LGE with the MR fraction and the presence of ComVA. We compared myocardial T1-native and post-contrast times and extracellular volume (ECV)-values between MVP patients, both with and without LGE, and the control group.ResultsThirty-four patients with MVP were selected (56 ± 14 years old, 59% male). All patients had MR; LGE and ComVA were present in 15 (44%) and 11 (34%) patients, respectively. Significant associations of LGE with both MR severity and ComVA were not found (p=0.72 and 0.79, respectively). T1 mapping confirmed the presence of LGE in all cases. In one patient a thin signal alteration resulted in more evident T1 mapping than LGE. Patients with MVP had higher native T1-values, lower post-contrast T1-values and increased ECV-values compared with controls (p=0.01, 0.01 and 0.00, respectively).ConclusionFocal fibrosis with LGE was found in about half the MVP patients and it was independent of the degree of the valve dysfunction and the presence of ComVA. T1 mapping allows diffuse myocardial wall alterations to be identified, but no significant associations between the MR severity and ComVA and T1/ECV values were found.Key Points• MVP is a common valvulopathy affecting 2–3% of the general population.• MVP has been associated with an increased risk of arrhythmic complications and suddencardiac death.• CMR is a non-invasive imaging method that provides a precise and more accurate assessmentof patients with MVP.

Diffusion-Weighted and Perfusion-Weighted MRI to Evaluate Therapeutic Response in Lymphoma: A Comparison with FDG-PET/CT

This prospective study sought to compare the diagnostic performance of advanced MR imaging (MRI) with PET/CT. In particular, we aimed to investigate whether MRI can decrease the false-positive or false-negative rate and could be a valid alternative to PET/CT evaluations. From December 2015 to May 2017, we enrolled 25 consecutive patients (17 females and 8 males aged 40.5 ± 16 years) with a histological diagnosis of lymphoma, and who had residual disease of ≥3 cm at the end of therapy. All patients underwent MRI and PET/CT 3–4 months after the end of immuno-chemotherapy and chemotherapy plus radiotherapy. The ethics committee of our institution approved this prospective study. All patients provided their written informed consent for the study, MRI, and PET/CT examination. MR images were acquired using a 1.5-T tomograph (Magnetom Aera, Siemens Healthcare, Germany). The MR protocol included ECG-gated sequences (T1-weighted [T1w], T2w, T2 SPAIR, and T1 FLASH before and after the administration of gadolinium chelate contrast agent), DwI, and PwI. The residual masses were analyzed by 2 radiologists experienced in MRI. They evaluated 3 parameters: morphological-contrastographic (MC) feaThe treatment of both Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL) frequently results in residual masses [1]. A high-prognostic-value imaging modality is needed to assess the response to treatment and identify patients with active disease within the residual mass. Positron emission tomography/computed tomography (PET/CT) allows for a complete assessment of the whole body and is now considered an essential tool to evaluate the posttreatment response in fluorodeoxyglucose (FDG)-avid lymphoma [2], although its accuracy is challenging. In long-term follow-up, often in young patients, an important issue to consider is the exposure to ionizing radiation. The mean effective dose of PET/CT examinations is 19.6 ± 6.1 mSv [3], corresponding with the radiation of about 1,000 chest X-rays and 10 head CTs [4]. Few studies have investigated the role of advanced magnetic resonance (MR) techniques by the 2 quantitative parameters, diffusion-weighted imaging (DwI) and perfusion-weighted imaging (PwI). DwI is able to provide an assessment of tumor cellular cramming, while PwI can quantitatively evaluate the combined effects of plasma blood flow, permeability, and capillary surface area. Received: October 25, 2017 Accepted after revision: November 18, 2017 Published online: January 26, 2018

Sudden cardiac death in a patient with advanced hepatocellular carcinoma with good response to sorafenib treatment: A case report with literature analysis

Hepatocellular carcinoma (HCC) is the principal primary liver tumor, representing the third largest cause of cancer-associated death worldwide. The actual reference standard systemic treatment for advanced HCC is represented by sorafenib, a multi-targeted orally active small-molecule tyrosine kinase inhibitor. Sorafenib has exhibited a good general safety profile in multiple clinical trials. However, adverse drug-associated events are common, occasionally severe, and special attention should be paid to cardiovascular adverse events, particularly in patients with risk factors or known heart disease. In the present study, the case of a patient with no known cardiovascular risk factors affected by highly enhancing advanced HCC in cirrhotic liver, who died during successful sorafenib monotherapy, is reported.

MR imaging in non-hepatosplenic extramedullary hematopoiesis in primary myelofibrosis

A 49-year-old man, diagnosed 2 years earlier with primary myelofibrosis (PMF), presented with a complaint of progressive dysesthesias involving the left leg and foot. When PMF was diagnosed, grade 3 fibrosis at bone marrow examination, an atypical CALR mutation, wild type JAK2 and MPL genes, male karyotype with translocation t(8;12), and 1% blasts in peripheral blood were present; additional findings included splenomegaly of 17 cm at longitudinal diameter and night sweats, consistent with intermediate-2 IPSS score [1], low molecular risk for absence of mutations in ASXL1, EZH2, IDH1/2, and SRSF2 genes [2]. Immediately after the diagnosis, he was enrolled in a phase I/II trial of association ruxolitinib-sonidegib. During treatment, dysesthesias worsened. Electromyography showed peripheral symmetric sensory and motor neuropathy. Spin cerebellar ataxia, autoimmune disorders, and atypical infections were excluded. Magnetic resonance imaging (MRI) of brain was negative, but spine MRI showed a bulky mass surrounding vertebral bodies from D4 to S4; this tissue was thicker in the middle dorsal segment, with early neural foramen involvement (L4-L5; L5-S1), without bone erosion. The lesion was smooth, well defined and it displayed cleavage planes with the great vessels (Image A–E arrows). A CT-guided biopsy of the paravertebral mass was performed and extramedullary hematopoiesis (EMH) was diagnosed. The correlation between molecular and calreticulin immune-histochemical assays was confirmed (Image F–H) [3]. No changes was detected at bone marrow re-examination and the class of risk was DIPSS intermediate-1 for peripheral blasts >1% [4] and DIPSS plus intermediate-2 for platelet count <100 3 10/L, respectively. The t(8;12) was still present but not included in unfavorable karyotypes [5]. The patient was treated with radiotherapy (30 Gray) on the lumbar localization. No improvement was reported; later, bone marrow transplantation procedure was performed, but patient died due to acute graft versus host disease. Image 1. (A) Spine MRI on sagittal fat-sat T2-weighted scan shows a paraspinal soft tissue swelling (white arrows), strongly hyperintense to muscle and bone marrow. (B, C) Axial MRI scans confirm the paravertebral lesion (white arrows) isointense to muscle and slightly hyperintense to bone marrow on T1weighted images (B), slightly hyperintense to muscle and bone marrow on T2-weighted images (C). (D) After Gadolinium chelate contrast agent administration, a uniform and clear enhancement was detectable (white arrows). (E) Heavily diffusion-weighted axial scan show mild signal intensity (white arrows). (F–H) Histological examination of the paravertebral mass shows EMH with scattered multinucleated cells and atypical megakaryocytes, gathered in clusters, admixed with adypocytes in the context of a fibrous stroma (F, H&E, original magnification 340). Immunoreactivity for factor VIII antigen identifies large elements as megakaryocytes with atypical morphology (G, original magnification 340). Calreticulin antibody stains atypical megakaryocytes (H). (I–L) Outline of paraspinal EMH (black thick arrows) derived from our case (I) and typical localization derived from Orphanidou-Vlachou et al. [9] (L).