Lorenzo Faggioni

80-kV Pulmonary CT Angiography With 40 mL of Iodinated Contrast Material in Lean Patients: Comparison of Vascular Enhancement With Iodixanol (320 mg I/mL)and Iomeprol (400 mg I/mL)

OBJECTIVE The purpose of this article is to compare the vascular enhancement obtained with a low-kilovoltage pulmonary CT angiography (CTA) protocol in lean patients, using 40 mL of a moderate-concentration isoosmolar (iodixanol, 320 mg I/mL) and a high-concentration low-osmolar (iomeprol, 400 mg I/mL) iodinated contrast medium injected at the same iodine delivery rate. SUBJECTS AND METHODS Forty-two lean patients (31 men and 11 women; body mass index, ≤ 23 kg/m(2)) with suspected pulmonary embolism and non-small cell lung carcinoma underwent pulmonary CTA with a 64-MDCT scanner using a tube voltage of 80 kV. Twenty-three patients (54.8%) received 40 mL of iodixanol (320 mg I/mL) injected at a rate of 5 mL/s, and the remaining 19 patients (45.2%) were administered an equal volume of iomeprol (400 mg I/mL) at a flow rate of 4 mL/s. Intraarterial density was measured in the common pulmonary artery trunk, the main right and left pulmonary arteries, lobar arteries, and at the segmental level, for a total of 15 regions of interest per patient. Intravascular enhancement homogeneity from central to subsegmental level was also assessed visually using a semiquantitative score (1 = poor, 2 = good, and 3 = excellent). RESULTS The overall vascular density of pulmonary arteries down to the segmental level was significantly higher with iodixanol (320 mg I/mL) than with iomeprol (400 mg I/mL) (p = 0.036). Enhancement homogeneity was good with both contrast agents, with no statistically significant difference between them (p = 0.8966). CONCLUSION In 80-kV pulmonary CTA of lean patients, higher intravascular enhancement can be achieved with 40 mL of iodixanol (320 mg I/mL) than with the same volume of iomeprol (400 mg I/mL), with good vessel conspicuity down to the subsegmental level.

Assessment of midbrain atrophy in patients with progressive supranuclear palsy with routine magnetic resonance imaging

Objectives –  To assess midbrain atrophy through morphometric (linear, surface and volumetric) measurements in patients with clinically diagnosed progressive supranuclear palsy (PSP) and to establish the most accurate measure to be implemented in routine magnetic resonance (MR) protocol in distinguishing PSP from healthy subjects and MSA‐p (multiple system atrophy, parkinsonian form) patients.

The future of PACS in healthcare enterprises

Picture Archiving and Communication System (PACS), which was originally designed as a tool for facilitating radiologists in interpreting images more efficiently, is evolving into a hospital-integrated system storing diagnostic imaging information that often reaches far beyond Radiology. The continuous evolution of PACS technology has led to a gradual broadening of its applications, ranging from teleradiology to CAD (Computer-Assisted Diagnosis) and multidimensional imaging, and is moving into the direction of providing access to image data outside the Radiology department, so to reach all the branches of the healthcare enterprise. New perspectives have been created thanks to new technologies (such as holographic media and GRID computing) that are likely due to expand PACS-based applications even further, improving patient care and enhancing overall productivity.

CT perfusion of head and neck tumors: how we do it.

OBJECTIVE Our purpose is to illustrate the pathophysiologic, physical, and technical principles of MDCT perfusion imaging of head and neck tumors. The rationale for data acquisition and the interpretation of perfusion parameters will be discussed in the context of results recently published in the literature. CONCLUSION MDCT perfusion imaging of primary and recurrent head and neck tumors is feasible and can yield functional information that is useful for tumor grading and assessment of treatment response.

Osteoid osteoma in atypical locations: The added value of dynamic gadolinium-enhanced MR imaging

PURPOSE To compare the results of dynamic gadolinium-enhanced magnetic resonance imaging (MRI), unenhanced MRI and computed tomography (CT), in terms of nidus conspicuity and diagnostic confidence of osteoid osteoma in atypical sites. MATERIALS AND METHODS CT and MR (nonenhanced T1- and T2-weighted and dynamic MRI) images of 19 patients with histologically proven osteoid osteoma located in atypical sites were retrospectively reviewed. Time-enhancement curves of the nidus and the adjacent bone marrow were generated. Images from each technique were scored for nidus conspicuity by two independent radiologists. Another blinded radiologist was asked to assess final diagnosis of the bone lesion on MR and CT images, independently. RESULTS In all cases, nidus contrast uptake started in the arterial phase and was higher compared to the surrounding bone marrow. Dynamic MRI significantly increased nidus conspicuity compared to nonenhanced MRI (P<.0001) and CT (P=.04). In 6/19 (31.6%) cases nidus conspicuity was higher at dynamic MRI compared to CT. Confident diagnosis of osteoid osteoma was achieved in all patients with MRI and in 10/19 (52.6%) patients with CT. CONCLUSION In patients with osteoid osteoma located in atypical sites, dynamic MRI increases nidus conspicuity, allowing confident diagnosis.

Long-term results of sorafenib in advanced-stage hepatocellular carcinoma: what can we learn from routine clinical practice?

Background and aims: Prospective randomized trials have proven that sorafenib is a valid treatment option for patients with advanced-stage hepatocellular carcinoma (HCC). The aim of the present study is to evaluate the effectiveness and safety of sorafenib in patients encountered in routine clinical practice. Methods: From September 2008 to March 2011, 42 cirrhotic patients (30 male; 12 female; mean age: 70.2 ± 7.6 years; range: 56–85 years) with HCC of Barcelona Clinic Liver Cancer stage B (n = 5) or C (n = 37; mean size: 66.6 ± 42.3 mm; mean number per patient: 3.3 ± 2.8) were treated with sorafenib at either a standard dose of 800 mg/day (n = 29; 69.1%) or at 400 mg/day with subsequent dose escalation (ramp-up strategy; n = 13, 30.9%). Baseline clinical parameters were comparable. Clinical data and side effects, laboratory analyses (in particular, serum α-fetoprotein) and radiological data (tumor response according to amended RECIST criteria) were assessed every 3 months. Survival was calculated by Kaplan–Meier analysis. Results: Mean follow-up was 12.2 ± 9 months (range: 1–32 months). Median overall survival was 26.1 months with overall 6- and 12-month survival rates of 92.1 and 85%, respectively. Median time to radiological progression was 8 months. The progression-free rate was 64.3%. Fatigue, skin disorders and diarrhea were the most frequent grade 3–4 side effects. Treatment discontinuation occurred in 25 patients. The starting dose for the last 13 enrolled patients was 400 mg/day; in the absence of toxicity this dosage was gradually increased to 800 mg/day after 3 weeks (‘ramp-up strategy’). No grade 3/4 adverse events were observed in the ramp-up group. Conclusion: Sorafenib is a valid treatment option for advanced-stage HCC. Starting at a lower dosage may allow prolonged compliance to treatment and might be considered according to patient tolerance.

Optimizing the Balance Between Radiation Dose and Image Quality in Pediatric Head CT: Findings Before and After Intensive Radiologic Staff Training

OBJECTIVE The purpose of this study was to assess the radiation dose and image quality of pediatric head CT examinations before and after radiologic staff training. MATERIALS AND METHODS Outpatients 1 month to 14 years old underwent 215 unenhanced head CT examinations before and after intensive training of staff radiologists and technologists in optimization of CT technique. Patients were divided into three age groups (0-4, 5-9, and 10-14 years), and CT dose index, dose-length product, tube voltage, and tube current-rotation time product values before and after training were retrieved from the hospital PACS. Gray matter conspicuity and contrast-to-noise ratio before and after training were calculated, and subjective image quality in terms of artifacts, gray-white matter differentiation, noise, visualization of posterior fossa structures, and need for repeat CT examination was visually evaluated by three neuroradiologists. RESULTS The median CT dose index and dose-length product values were significantly lower after than before training in all age groups (27 mGy and 338 mGy ∙ cm vs 107 mGy and 1444 mGy ∙ cm in the 0- to 4-year-old group, 41 mGy and 483 mGy ∙ cm vs 68 mGy and 976 mGy ∙ cm in the 5- to 9-year-old group, and 51 mGy and 679 mGy ∙ cm vs 107 mGy and 1480 mGy ∙ cm in the 10- to 14-year-old group; p < 0.001). The tube voltage and tube current-time values after training were significantly lower than the levels before training (p < 0.001). Subjective posttraining image quality was not inferior to pretraining levels for any item except noise (p < 0.05), which, however, was never diagnostically unacceptable. CONCLUSION Radiologic staff training can be effective in reducing radiation dose while preserving diagnostic image quality in pediatric head CT examinations.

Anatomical landmarks for transoral robotic tongue base surgery: comparison between endoscopic, external and radiological perspectives

PurposeTo describe the transoral viewpoint of the tongue base anatomy, focusing on a superior to inferior perspective, which is less familiar to the head and neck surgeon but, at the same time, worthy to be known given the expanding interest and diffusion of the transoral robotic technique.MethodsSeven heads were dissected, two with the Da Vinci® robotic system, three by means of a transoral endoscopic approach and another two by means of a lateral “traditional” external approach. Ten normal patients, with normal oral cavity and oropharynx, were studied as control samples by means of a 3-T MRI scanner.ResultsMajor neurovascular elements are placed laterally and deeply within the tongue base. Dissection within intrinsic and genioglossus muscles is safe because the main trunk of the lingual artery lies on the lateral surface of genioglossus muscle, covered by the hyoglossus muscle. The hypoglossal nerve, with its comitant vein, is more lateral, lying on the external surface of the hyoglossus muscle. Radiological evaluation can visualize important details of this complex anatomy. The position of the vessels can be directly identified, whereas major nerves are more difficult to be visualized unless they are surrounded by fibro-fatty tissue.ConclusionsA medial to lateral dissection of the tongue base can be considered safe. A strict collaboration with the radiologist is helpful in approaching these cases by means of a robotic technique and in improving a true 3D understanding of this complex anatomy.

Assessment of response to sorafenib in advanced hepatocellular carcinoma using perfusion computed tomography: Results of a pilot study

AIMS This prospective pilot study investigated the feasibility of perfusion computed tomography parameters as surrogate markers of angiogenesis and early response following sorafenib administration in patients with advanced hepatocellular carcinoma. METHODS Ten patients were evaluated with perfusion computed tomography before starting sorafenib and after 3 months. Blood flow, blood volume, mean transit time, hepatic arterial fraction, and permeability surface-product were compared in tumour lesions and in hepatic parenchyma at baseline and at follow-up. Correlation between these parameters and changes in alpha-fetoprotein levels was calculated. RESULTS At baseline, blood volume, blood flow, hepatic arterial fraction and permeability surface values were higher in lesions compared to those in hepatic parenchyma, while mean transit time was lower (p<0.05). After sorafenib treatment, only mean transit time was significantly increased versus baseline (p<0.05). At follow-up, plasma alpha-fetoprotein levels decreased in all patients. At follow-up, an inverse correlation was observed between baseline mean transit time and changes in alpha-fetoprotein (r=-0.6685, p=0.0125), as well as a correlation between baseline blood flow and alpha-fetoprotein (r=0.6476, p=0.0167). CONCLUSION This pilot study suggests that after sorafenib treatment an increase in mean transit time observed in tumour lesions is inversely correlated with alpha-fetoprotein reductions after therapy. Mean transit time may represent a possible marker of response irrespectively of alpha-fetoprotein values.

Integrating image processing in PACS

Integration of RIS and PACS services into a single solution has become a widespread reality in daily radiological practice, allowing substantial acceleration of workflow with greater ease of work compared with older generation film-based radiological activity. In particular, the fast and spectacular recent evolution of digital radiology (with special reference to cross-sectional imaging modalities, such as CT and MRI) has been paralleled by the development of integrated RIS--PACS systems with advanced image processing tools (either two- and/or three-dimensional) that were an exclusive task of costly dedicated workstations until a few years ago. This new scenario is likely to further improve productivity in the radiology department with reduction of the time needed for image interpretation and reporting, as well as to cut costs for the purchase of dedicated standalone image processing workstations. In this paper, a general description of typical integrated RIS--PACS architecture with image processing capabilities will be provided, and the main available image processing tools will be illustrated.