Lucia Manganaro

Imaging for the evaluation of endometriosis and adenomyosis.

Endometriosis affects between 5 and 45% of women in reproductive age, is associated with significant morbidity, and constitutes a major public health concern. The correct diagnosis is fundamental in defining the best treatment strategy for endometriosis. Therefore, non-invasive methods are required to obtain accurate diagnoses of the location and extent of endometriotic lesions. Transvaginal sonography and magnetic resonance imaging are used most frequently to identify and characterise lesions in endometriosis. Subjective impression by an experienced sonologist for identifying endometriomas by ultrasound showed a high accuracy. Adhesions can be evaluated by real-time dynamic transvaginal sonography, using the sliding sign technique, to determine whether the uterus and ovaries glide freely over the posterior and anterior organs and tissues. Diagnosis is difficult when ovarian endometriomas are absent and endometriosis causes adhesions and deep infiltrating nodules in the pelvic organs. Magnetic resonance imaging seems to be useful in diagnosing all locations of endometriosis, and its diagnostic accuracy is similar to those obtained using ultrasound. Transvaginal ultrasound has been proposed as first line-line imaging technique because it is well accepted and widely available. The main limitation of ultrasound concerns lesions located above the rectosigmoid junction owing to the limited field-of-view of the transvaginal approach and low accuracy in detecting upper bowel lesions by transabdominal ultrasound. A detailed non-invasive diagnosis of the extension in the pelvis of endometriosis can facilitate the choice of a safe and adequate surgical or medical treatment.

Potential role of fetal cardiac evaluation with magnetic resonance imaging: preliminary experience

To report our experience with magnetic resonance imaging (MRI) in fetal heart evaluation.

Evaluation of normal brain development by prenatal MR imaging.

AbstractPurpose.The aim of this study was to describe the normal pattern of development and maturation of the foetal brain with respect to gestational age as assessed with magnetic resonance imaging (MRI) and to provide an overview of the possibilities of the technique.Materials and methods.Foetal cerebral MRI was performed on 56 pregnant women between 19 and 37 weeks of gestation. Half-Fourier single-shot turbo spin-echo (HASTE), true fast imaging with steady precession (FISP), T1-weighted fast low angle shot (FLASH) two-dimensional (2D) and diffusion-weighted (DW) sequences with apparent diffusion coefficient (ADC) were obtained. Biometric parameters and developmental areas of the cerebral cortex were correlated to gestational age by using the Spearman rank correlation test.Results.We found a negative correlation between the germinal matrix/biparietal diameter ratio and gestational age and a positive correlation between the germinal and cortical matrix when expressed as external intraocular diameter ratio (R=0.452, p=0.02). The cortical mantle was correlated with biometric parameters, such as the biparietal diameter and the frontooccipital diameter, and with gestational age. The interhemispheric fissure, the parietooccipital fissure and the sylvian fissure were detectable by the 22nd week. In the grey matter, the mean ADC values varied from 1.76×10-3 mm2/s (at week 19) to 0.89×10-3 mm2/s (at week 37), whereas in the white matter, the values varied from 2.03×10-3 mm2/s (at week 19) to 1.25×10-3 mm2/s (at week 37).Conclusions.MRI provides a reliable valuation of brain maturation during pregnancy.

Role of breast Magnetic Resonance Imaging (MRI) in patients with unilateral nipple discharge: preliminary study

PurposeThis study was performed to assess the role of magnetic resonance imaging (MRI) in patients with unilateral nipple discharge.Materials and methodsForty-four patients with bloody or serosanguineous nipple discharge and negative mammographic findings (35/44 cases) underwent MRI for evaluation of breast ducts. Ultrasonography, negative in 18 patients, identified 26 cases of ductal ectasia (12 simple, nine with solid intraductal echoes and wall thickening, five with inhomogeneous parenchyma). Galactography was negative in three patients and positive in nine. Nineteen patients were followed up by clinical examination, ultrasonography, and cytological evaluation of nipple discharge (6–12 months); three patients underwent excisional biopsy, ten core biopsy and 12 cytological biopsy (followed by excisional biopsy).ResultsMRI identified 25 enhancing lesions Breast Imaging Reporting and Data Systems (BI-RADS) 3 or 4) and confirmed the galactographic findings (ductal ectasia, intraluminal filling defects). Five papillomatoses appeared as patchy, homogeneous enhancing areas, 15 intraductal papillomas as areas with well-defined margins and type II time-intensity curves, and two atypical ductal hyperplasias as diffuse nodular enhancement. One micropapillary ductal carcinoma in situ (DCIS), one papillary carcinoma and one infiltrating ductal carcinoma (IDC) were visualised as two segmental areas of enhancement and one mass-like enhancement with poorly defined margins (BI-RADS 4). The follow-up was negative, showing no pathological enhancement (BI-RADS 1) in 12 patients and benign enhancement (BI-RADS 2) in seven.ConclusionsBreast MRI can be considered a valuable examination in the diagnosis of suspected ductal disease and an alternative to galactography when the latter cannot be used.RiassuntoObiettivoValutare il ruolo della risonanza magnetica (RM) in pazienti con secrezione monorifiziale dal capezzolo.Materiali e metodiQuarantaquattro pazienti con secrezione ematica/sieroematica dal capezzolo, mammografia negativa (35/44 casi) si sottoponevano allo studio dei dotti con RM. L’ecografia negativa in 18 casi, identificava ectasia duttale in 26: semplici in 12, con proliferazione solida intraduttale ed ispessimento parietale in 9 e con disomogeneità ghiandolare in 5; la galattografia negativa in 3 e positiva in 9. Diciannove pazienti effettuavano follow-up clinico, radiologico, citologico della secrezione (6–12 mesi), 3 biopsia chirurgica, 10 core-biopsy e 12 prelievo citologico (seguite da biopsia chirurgica).RisultatiRM identificava 25 aree di potenziamento classificate BI-RADS 3 o 4. Nelle pazienti sottoposte a galattografia, la RM riconosceva i reperti galattografici (ectasia o difetti di riempimento). Cinque papillomatosi duttali si identificavano come potenziamento lineare ed omogeneo; 15 papillomi: enhancement a margini netti e curva intensità-tempo di tipo II, 2 iperplasie duttali atipiche: potenziamento nodulare diffuso. Un carcinoma papillare, 1 CDIS con aspetto micropapillare e 1 CDI si evidenziavano come 2 aree di potenziamento segmentale e un’area di potenziamento nodulare a margini irregolari (BI-RADS4). Follow-up negativo in 12 pazienti senza potenziamento patologico (BI-RADS1) e in 7 con potenziamento benigno (BIRADS2).ConclusioniLa RM può essere considerata valida metodica diagnostica nello studio della sospetta patologia duttale con secrezione, in alternativa alla galattografia quando questa metodica non sia utilizzabile.

Feasibility of 3.0 T pelvic MR imaging in the evaluation of endometriosis

INTRODUCTION Endometriosis represents an important clinical problem in women of reproductive age with high impact on quality of life, work productivity and health care management. The aim of this study is to define the role of 3T magnetom system MRI in the evaluation of endometriosis. MATERIALS AND METHODS Forty-six women, with transvaginal (TV) ultrasound examination positive for endometriosis, with pelvic pain, or infertile underwent an MR 3.0T examination with the following protocol: T2 weighted FRFSE HR sequences, T2 weighted FRFSE HR CUBE 3D sequences, T1 w FSE sequences, LAVA-flex sequences. Pelvic anatomy, macroscopic endometriosis implants, deep endometriosis implants, fallopian tube involvement, adhesions presence, fluid effusion in Douglas pouch, uterus and kidney pathologies or anomalies associated and sacral nervous routes were considered by two radiologists in consensus. Laparoscopy was considered the gold standard. RESULTS MRI imaging diagnosed deep endometriosis in 22/46 patients, endometriomas not associated to deep implants in 9/46 patients, 15/46 patients resulted negative for endometriosis, 11 of 22 patients with deep endometriosis reported ovarian endometriosis cyst. We obtained high percentages of sensibility (96.97%), specificity (100.00%), VPP (100.00%), VPN (92.86%). CONCLUSION Pelvic MRI performed with 3T system guarantees high spatial and contrast resolution, providing accurate information about endometriosis implants, with a good pre-surgery mapping of the lesions involving both bowels and bladder surface and recto-uterine ligaments.

Fetal MRI as a complement to US in the evaluation of cleft lip and palate

PurposeThe aim of our study was to investigate the role of fetal magnetic resonance imaging (MRI) as a complement to ultrasound (US) in the evaluation of cleft lip and palate (CLP), whether isolated or in association with syndromic conditions.Materials and methodsWe enrolled 24 pregnant women (27 fetuses) (mean gestational age 23.7 weeks) with a level-two US diagnosis of cleft lip (CL) or CLP with or without associated central nervous system (CNS) or facial-bone anomalies. All individuals underwent a fetal MRI examination to study the facial skeleton, CNS and fetal body. For each fetus, the main anatomical facial landmarks and biometric parameters [anteroposterior diameter (APD), biparietal diameter (BPD), inferior facial angle (IFA), frontomaxillary angle (FMA), bi-orbital diameter (BOD), intraorbital diameter (IOD)] were measured.ResultsTwenty-five of 27 fetuses had a US diagnosis of CL or CLP. MRI confirmed the diagnosis in 16/25 fetuses and added information about the extent of the cleft and the degree of involvement of the anterior and posterior palate in 8/25 fetuses. MRI ruled out the diagnosis in 1/25 fetuses and identified an alteration of the parameters IFA, FMA and IOD in 6/24 fetuses.ConclusionsIn the study of CLP fetal, MRI is able to define the degree of involvement of the posterior palate and the lateral extent of the cleft with higher diagnostic accuracy than US. Furthermore, MRI provides a complete study of the fetal head and biometric development of the facial bones, thus enabling early detection of potential syndromic conditions.RiassuntoObiettivoLo scopo del nostro studio è valutare il ruolo complementare, rispetto all’esame ecografico, della risonanza magnetica (RM) fetale nell’inquadramento delle labioschisi (LBS) o labio-palatoschisi (LPS) isolate e associate a quadri sindromici.Materiali e metodiAbbiamo prospettivamente arruolato 24 donne in gravidanza (27 feti; età gestazionale media 23,7 settimane) con diagnosi ecografica di II livello di LBS o LPS, associata o meno ad anomalie cranio-encefaliche o del massiccio facciale; le pazienti sono state sottoposte a RM fetale per lo studio del massiccio facciale, oltre che del sistema nervoso centrale (SNC) e del body fetale. Per ogni feto abbiamo valutato i principali reperi anatomici del massiccio facciale e calcolato i seguenti parametri riguardanti il suo normale sviluppo: diametro anteroposteriore della mandibola (DAPM), diametro biparietale della mandibola (DBPM), angolo facciale inferiore (IFA), angolo fronto-mascellare (FMA), diametro bisorbitario (DBO), diametro interorbitario (DIO).RisultatiVenticinque/27 feti avevano diagnosi ecografica di LBS-LPS. La RM ha confermato la diagnosi ecografica in 16/25 feti ed ha aggiunto informazioni riguardo l’estensione della schisi ed il coinvolgimento del palato in 8/25 feti; ha smentito la diagnosi in 1/25 feti. Inoltre abbiamo evidenziato in 6/24 feti un’alterazione dei parametri IFA, FMA, DIO.ConclusioniLo studio RM fetale del massiccio facciale nelle LBS-LPS definisce con maggiore accuratezza il grado di coinvolgimento del palato posteriore e la lateralità; consente, inoltre, una valutazione del distretto cranioencefalico e dello sviluppo biometrico del massiccio facciale al fine di identificare precocemente eventuali condizioni sindromiche.

Differential Diagnosis of Nonpalpable Testicular Lesions: Qualitative and Quantitative Contrast-enhanced US of Benign and Malignant Testicular Tumors

PURPOSE To evaluate the diagnostic accuracy of unenhanced and quantitative contrast-enhanced ultrasonography (US) in the differential diagnosis of small nonpalpable testicular lesions. MATERIALS AND METHODS The local review board approved the protocol, and all patients provided written informed consent. One hundred fifteen patients (median age, 34 years; age range, 14-61 years) with nonpalpable testicular lesions were consecutively enrolled between 2006 and 2012 and underwent unenhanced scrotal US, contrast-enhanced US, surgical enucleation, and at least 18 months of follow-up. Clinical and histologic features were recorded, and qualitative and quantitative analysis of contrast-enhanced US time-intensity curves were performed. Logistic regression analysis was performed to explore features of malignancy. Receiver operating characteristic ( ROC receiver operating characteristic ) curves were developed for cumulative unenhanced and contrast-enhanced US scores. RESULTS All lesions were 1.5 cm or smaller. Forty-four of the 115 patients (38%) had malignant tumors, 42 had benign tumors (37%), and 29 (25%) had nonneoplastic lesions. The features at unenhanced US that enabled the best differentiation of tumors versus nonneoplastic lesions and benign versus malignant tumors were parenchymal microlithiasis (26 of 86 patients with tumors vs five of 29 patients with nonneoplastic lesions [P = .178]; four of 42 patients with benign lesions vs 22 of 44 patients with malignant tumors [P < .001]), irregular margins (26 of 86 patients with tumors vs three of 29 patients with nonneoplastic lesions [P < .001]; eight of 42 patients with benign lesions vs 18 of 44 patients with malignant tumors [P < .001]), and internal vascularization (70 of 86 patients with tumors vs seven of 29 patients with nonneoplastic lesions [P < .001]; 28 of 42 patients with benign lesions vs 42 of 44 patients with malignant tumors [P < .001]). For contrast-enhanced US, the rapidity of wash-in (34 of 44 patients vs 15 of 42 patients, P < .001) and washout (33 of 44 patients vs five of 42 patients, P < .001) were the parameters that best differentiated malignant from benign tumors, with a typical prolonged washout observed in Leydig cell tumors (12 of 21 patients, P < .001 when compared with seminomas). Overall, the combination of unenhanced and contrast-enhanced US achieved a high accuracy in the diagnosis of small testicular malignancies (area under the ROC receiver operating characteristic curve performance: 0.927; 95% confidence interval: 0.872, 0.981). CONCLUSION Benign testicular tumors are frequent incidental findings. Quantitative scrotal contrast-enhanced US is a noninvasive diagnostic tool that could improve the differential diagnosis and individualized management of small testicular lesions.

Role of fetal MRI in the diagnosis of cerebral ventriculomegaly assessed by ultrasonography

PurposeTo evaluate the additional diagnostic value of fetal MRI to evaluate cerebral ventriculomegaly assessed by ultrasonography (US) for the possibility to change the diagnosis, the counseling and the management of pregnancy.Materials and MethodsFrom february 2006 to october 2008, we studied 55 pregnant women by fetal MRI (mean age 28 years), 4 with twin pregnancy, for a total of 59 fetuses with mean gestational age of 27 weeks. The number of fetuses affected by ventriculomegaly assessed by US was 55. All fetuses had a US diagnosis of ventriculomegaly: 29 fetuses with isolated ventriculomegaly and 26 fetuses with ventriculomegaly associated with CNS (central nervous system) abnormalities (18) and with no CNS abnormalities (8).ResultsThe findings showed that the two techniques are substantially in agreement in defining the degree of VM, with the exception of some cases in which the disagreement could be attributed to the possible progression of the dilatation between the US and MRI examinations, which sway between two days and two weeks. We proved a low correlation between US and MRI in the evaluation of ventriculomegaly associated either with CNS or non-CNS anomalies: in fact while fetal MRI detected 26/55 (47,3%) VM associated with CNS anomalies, US demonstrated only 18/55(32,7%). Referring to VM associated with non-CNS anomalies, MRI diagnosed 10/55 cases (18,2%) compared to 8/55 fetuses (14,5%) showed by US.ConclusionsOur experience demonstrated that fetal MRI has an important role as adjunctive tool to sonography in the evaluation of cerebral ventriculomegaly for the additional informations given to parents and for the possibility to change the diagnosis, the counseling and the management of pregnancy.RiassuntoObiettivoLo scopo del nostro studio è valutare il ruolo della risonanza magnetica nell’inquadramento diagnostico delle ventricolomegalie per le conseguenze che un cambiamento della diagnosi può avere sul counselling materno, sul management della gravidanza e sulla pianificazione di eventuali interventi pre e postnatali, nell’ottica di una gestione multidisciplinare.Materiali e metodiNel periodo compreso fra febbraio 2006 ed ottobre 2008, abbiamo sottoposto a risonanza magnetica 55 donne in stato di gravidanza (età media 28 aa), 4 delle quali con gravidanze gemellari, per un totale di 59 feti di età gestazionale con età gestazionale media di 27 settimane. Il numero di feti interessati da ventricolomegalia secondo l’indicazione ecografica era di 55. Tutti i feti avevano diagnosi ecografica di ventricolomegalia: 29 feti con ventricolomegalia isolata e 26 feti con ventricolomegalia associata; in particolare in quest’ultimo gruppo 18 feti riportavano associazioni con anomalie del SNC ed 8 feti con anomalie di altri distretti.RisultatiÈ emerso così che le due metodiche sono sostanzialmente in accordo nel definire l’entità della ventricolomegalia, fatta eccezione per alcuni casi nei quali la discordanza potrebbe attribuirsi alla possibile progressione della dilatazione nell’arco di tempo intercorso fra ecografia e risonanza magnetica, variabile fra 2 giorni e 2 settimane. Minor grado di accordo è invece emerso dal confronto rispetto alla associazione delle ventricolomegalie con ulteriori anomalie sia del SNC fetale che di altri organi e apparati. Infatti la RM ha evidenziato 26/55 (47,3%) VM associate ad anomalie del SNC, versus 18/55 (32,7%) diagnosi di associazione con ulteriori anomalie encefaliche poste con l’ecografia; quanto alle associazioni con anomalie di altri distretti la RM ne ha posto diagnosi in 10/55 casi (18,2%) e l’ecografia in 8/55 feti (14,5%).ConclusioniIn base ai nostri risultati concludiamo che qualora si riscontri una ventricolomegalia vadano sempre informati i genitori circa il rischio di ulteriori anomalie associate e di conseguenti possibili ripercussioni sullo sviluppo psicomotorio del nascituro rispetto alla popolazione normale, consigliandone l’approfondimento diagnostico con i mezzi diagnostici disponibili.

Magnetic resonance imaging versus ultrasonography in fetal pathology.

PurposeThis paper describes our experience with magnetic resonance imaging (MRI) in the assessment of fetal anatomical structures and major fetal pathologies.Materials and methodsThe retrospective study included 128 pregnant women between the 22nd and 38th week of gestation. We used the following imaging protocol: T2-weighted single-shot fast spin-echo sequences for all foetuses and, in selected cases, gradient echo with steady-state free precession (SSFP), T1-weighted spoiled gradient echo [fast low-angle shot (FLASH)] with and without fat saturation, and T2 thick-slab sequences with multiplanar technique. In 32 cases, we performed diffusion-weighted sequences with apparent diffusion coefficient (ACD) maps on the brain, the kidneys and the lungs.ResultsWe achieved diagnostic-quality images in 125 of 128 patients; MR image quality was unsatisfactory in three cases only. In 16 cases with previous negative ultrasound (US) findings, MRI confirmed the US diagnosis. MRI confirmed the positive US diagnosis in 67 of 109 cases (61.5%); in 11 cases it changed the US diagnosis, and in 31/109 the examination was negative. In addition, MRI identified other anomalies not recognised during US examination.ConclusionsWith its ultrafast sequences, fetal MRI provides good detail of normal fetal anatomy and allows characterisation of suspected anomalies.RiassuntoObiettivoPresentare la nostra esperienza con la risonanza magnetica nella valutazione delle strutture anatomiche e delle patologie principali nel feto.Materiali e metodiLo studio retrospettivo include 128 donne in gravidanza tra la 22a e la 38a settimana di gestazione. Abbiamo utilizzato il seguente protocollo: per tutti i feti sequenze T2 pesate Single Shot Fast Spin Echo e in casi selezionati sequenze Gradient Echo con tecnica steady state free precession (SSFP), sequenze spoiled gradient echo T1 pesate (Fast Low Angle Shot, FLASH) con e senza saturazione del segnale del grasso e sequenze T2 thick slab acquisite con tecnica multiplanare. In 32 casi, abbiamo effettuato sequenze pesate per diffusione con il coefficiente di diffusione apparente (ADC) su cervello, reni e polmoni.RisultatiIn 125 pazienti su 128, l’esame ha mostrato una buona qualità; solo in 3 casi le immagini RM non sono risultate soddisfacenti. Nei 16 casi già negativi all’ecografia, l’RM ha confermato il risultato ecografico. L’RM ha confermato come positive 67 diagnosi ecografiche su 109 casi (61,5%); in 11 casi, invece, l’RM ha modificato la diagnosi ecografica ed in 31 pazienti l’esame è risultato negativo. Inoltre l’RM ha consentito di riconoscere ulteriori anomalie che non sono state diagnosticate durante l’esame ecografico.ConclusioniL’RM fetale, grazie alle sequenze ultra-fast, consente di visualizzare buoni dettagli dell’anatomia fetale e di caratterizzare sospette anomalie.

Beyond laparoscopy: 3-T magnetic resonance imaging in the evaluation of posterior cul-de-sac obliteration

OBJECTIVES Endometriosis is the ectopic localization of endometrial glands. Symptoms include a wide variety of chronic pelvic pain. Ovarian endometriosis represents the most frequent site of implantation followed by the Douglas pouch which is undepicted unless peritoneal fluid is present. Pelvic exams may be reported as normal in 40% of evaluations, although multiple nodularities are located in this region. Nowadays, laparoscopy represents the standard technique for endometriosis evaluation. However, magnetic resonance imaging (MRI) remains the best noninvasive technique for the evaluation of pelvic lesions. According to the importance of a precise preoperative diagnosis of deep infiltrative endometriosis involving the Douglas pouch, we evaluated feasibility of a 3-T system in the evaluation of this particular region. METHODS We enrolled 19 women coming with either ultrasound or anamnestic suspicion of endometriosis. Pelvic MRI examination was performed on the 3-T system. We applied a standard exam protocol including pulse sequences [single-shot fast spin echo (FSE)] and high-resolution T2W and T1W FSE sequences with and without FS. RESULTS MRI diagnosed posterior cul-de-sac obliteration in 15/19 patients. MRI findings were compared with laparoscopy, thus obtaining the following statistical values: mean sensitivity, specificity, positive predictive value and negative predictive value, respectively, of 93%, 75%, 93% and 75%. Moreover, we calculated an interobserver agreement k value of 0.72 with a substantial degree of agreement between two radiologists of a sensitivity value of 93% and specificity value of 75%. CONCLUSIONS Precise preoperative mapping of posterior cul-de-sac region is essential for a preoperative planning. In our work, the 3-T MRI was shown to be excellent in the evaluation of posterior cul-de-sac obliteration associated to an optimal evaluation of the uterosacral ligaments due to the higher contrast spatial resolution.