Marco Moschetta

Prognostic value of multidetector computed tomography in bowel infarction

PurposeThis study aimed to correlate computed tomography (CT) findings and outcomes in patients affected by bowel infarction.Materials and methodsTwenty-seven patients with bowel infarction due to vascular obstruction were evaluated with multidetector CT (MDCT) to establish the prognostic value of CT findings and their correlation with the origin of the ischaemia. The chi-square test was used to analyse the results (p≤0.05).ResultsMDCT images allowed recognition of the nature of ischaemia in all cases. In particular, arterial occlusion was found in 67% of patients and venous obstruction in 33%. The overall mortality rate was 63%. Outcome closely correlated with the kind of vascular obstruction, with a mortality rate of 89% in arterial forms and 11% in venous forms. Bowel-wall hyperdensity (2/9 venous occlusions), loss of wall enhancement (1/9 venous occlusions, 2/18 arterial occlusions) and wall thickening (8/9 venous obstructions, 2/18 arterial occlusions) were predictive of good outcome. Bowel-loop dilatation (4/9 venous occlusions, 13/18 arterial occlusions), intramural pneumatosis (1/9 venous occlusions, 17/18 arterial occlusions), mesenteric venous gas (2/9 venous occlusions, 11/18 arterial occlusions), portal venous gas (1/9 venous occlusions, 4/18 arterial occlusions), pneumoperitoneum (8/18 arterial occlusions) and pneumoretroperitoneum (1/18 arterial occlusions) were predictive of poor outcome. Ascites (6/9 venous occlusions, 12/18 arterial occlusions) did not add any prognostic information.ConclusionsMDCT is able to detect the nature of bowel ischaemia and provide important prognostic information.RiassuntoObiettivoRicercare eventuali correlazioni tra informazioni ottenute con tomografia computerizzata (TC) e prognosi nell’infarto intestinale.Materiali e metodiSono state valutate le immagini TC multidetettore (TCMD) di 27 pazienti con infarto intestinale da occlusione vascolare e sono state ricercate: significatività prognostica delle alterazioni evidenziate, correlazioni con la natura dell’ischemia. È stato applicato il test statistico del χ2 (p≤0,05).RisultatiLa TCMD ha riconosciuto sempre la natura dell’ischemia, secondaria ad occlusione arteriosa nel 67% dei casi e venosa nel 33%. Il tasso di mortalità complessivo è stato del 63%. L’eziologia della patologia in rapporto alla prognosi è risultata altamente significativa, con mortalità del 89% nelle forme arteriose e del 11% in quelle venose. L’iperdensità parietale (2/9 occlusioni venose), l’assenza di enhancement (1/9 occlusioni venose, 2/18 occlusioni arteriose), l’ispessimento di parete (8/9 occlusioni venose, 2/18 occlusioni arteriose) sono risultati significativi di evoluzione benigna, mentre la dilatazione delle anse (4/9 occlusioni venose, 13/18 occlusioni arteriose), la pneumatosi parietale (1/9 occlusioni venose, 17/18 occlusioni arteriose), l’aria nelle vene mesenteriche (2/9 occlusioni venose, 11/18 occlusioni arteriose), l’aria nei rami portali (1/9 occlusioni venose, 4/18 occlusioni arteriose), lo pneumoperitoneo (8/18 occlusioni arteriose) e il retropneumoperitoneo (1/18 occlusioni arteriose) sono risultati indici prognostici sfavorevoli. L’ascite (6/9 occlusioni venose, 12/18 occlusioni arteriose) non ha fornito indicazioni di tipo prognostico.ConclusioniLa TCMD consente di definire la natura dell’ischemia intestinale e fornisce importanti valutazioni prognostiche.

Deep pelvic endometriosis: accuracy of pelvic MRI completed by MR colonography

PurposeThis study assessed the diagnostic accuracy of pelvic magnetic resonance (MR) imaging completed by MR colonography for the preoperative evaluation of deep pelvic endometriosis in patients undergoing laparoscopic surgery.Materials and methodsA total of 143 patients (mean age 34.3±5.1 years) with a clinical suspicion of deep pelvic endometriosis were assessed by pelvic MR and MR colonography. All patients underwent laparoscopic surgery 3–10 weeks after the MR examination. The presence, location, number and extent of endometriotic lesions were evaluated. Data obtained with MR were compared with surgical findings. MR sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy values were calculated for each site by considering the laparoscopic and histological findings as the reference standard.ResultsLaparoscopy confirmed the presence of endometriosis in 119/143 patients (83%); in 76/119 (64%) deep pelvic endometriosis was diagnosed, whereas in the remaining 43/119 (36%), superficial peritoneal implants and endometriomas were found. In 32/119 (27%) patients, intestinal lesions were detected. MR had sensitivity, specificity, PPV, NPV and diagnostic accuracy values of 67–100%, 85–100%, 83–100%, 84–100% and 84–100%, respectively, in recognising lesions located in different pelvic sites.ConslucionsMR imaging combined with colonography is a highly accurate tool for characterising deep endometriotic lesions in patients scheduled for laparoscopic surgery. In particular, MR colonography has very high accuracy in detecting colorectal involvement.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’accuratezza diagnostica della risonanza magnetica (RM) pelvica associata a colonografia-RM nella valutazione preoperatoria della endometriosi pelvica profonda in pazienti sottoposte ad intervento per via laparoscopica.Materiali e metodiCentoquarantatre pazienti (età media 34,3±5,1 anni) con sospetto clinico di endometriosi pelvica profonda sono state valutate mediante RM pelvica completata con colonografia-RM. Tutte le pazienti sono state sottoposte a laparoscopia con un intervallo di 3–10 settimane dall’esame RM. Sono stati valutati presenza, sede, numero ed estensione delle lesioni endometriosiche. I dati ottenuti dalla RM sono stati confrontati con quelli chirurgici. Sensibilità, specificità, valore predittivo positivo (VPP) e negativo (VPN) ed accuratezza diagnostica della RM sono stati calcolati per ciascuna sede esaminata, considerando i reperti laparoscopici e istologici quale gold standard.RisultatiLa laparoscopia ha confermato la presenza di endometriosi in 119/143 pazienti (83%); in 76/119 (64%) era evidente endometriosi pelvica profonda, mentre nelle rimanenti 43/119 (36%) erano presenti endometriomi e impianti peritoneali superficiali. In 32/119 (27%) pazienti, sono state riscontrate lesioni intestinali. La RM ha presentato valori di sensibilità, specificità, VPP, VPN e accuratezza diagnostica rispettivamente compresi tra 67%–100%, 85%–100%, 83%–100%, 84%–100%, 84%–100% nel riconoscimento delle diverse sedi di impianto della patologia.ConclusioniLa RM associata a colonografia rappresenta una metodica accurata per lo studio delle pazienti con endometriosi pelvica profonda da sottoporre ad intervento chirurgico laparoscopico e per la caratterizzazione delle lesioni endometriosiche. In particolare la colonografia-RM consente elevati valori di accuratezza nell’identificazione delle lesioni intestinali.

An Optimized Feed-forward Artificial Neural Network Topology to Support Radiologists in Breast Lesions Classification

Introduction and objective: Computer Aided Decision (CAD) systems based on Medical Imaging could support radiologists in classifying malignant regions from benign ones, in the field of investigation for breast cancer detection. This decision may often follow a previous procedure dedicated to the earlier identification of Regions Of Interest (ROI) containing still unclassified lesions. Materials and methods: Materials comprise features extracted from magnetic resonance (MR) images representing morphological properties of lesions. The Regions Of Interest identified by a previous automatic procedure validated by radiologists of the University of Bari Aldo Moro (Italy), authors of this work, 134 from 600 slices considered of interest, because they contain still unclassified damaged areas. Several techniques were tested for ROI segmentation and classification. In particular, it can be shown that the same procedures for lesioned-area discrimination were also useful for malignancy classification of lesions, themselves. In particular, MR images were processed with different image processing techniques for ROI extraction, which were, ultimately, described by morphological features, such as circularity, aspect ratio, solidity and convexity. Finally, we discuss a procedure to design a feed-forward supervised artificial neural networks (ANN) architecture based on an evolutionary strategy. In a similar approach, different ANN topologies were tested in order to find the best in terms of mean accuracy for several iterations of training, validation and test. In particular, for each topology, the training, validation and test sets were constructed using 100 random permutations of the dataset, from which the average performances were calculated. Results: The performance of the best ANN architecture, trained using a training set of 82 samples (equally divided between malignant and benign lesions) from the 134 samples available in the whole dataset, were evaluated in terms of accuracy, sensitivity and specificity. Conclusion: Testing determined that the supervised ANN approach is consistent and reveals good performance; in particular, the optimal ANN topology found through an evolutionary strategy showed high generalization on the mean performance indexes regardless of training, validation and test sets applied, showing good performances in terms of both accuracy and sensitivity, permitting correct classification of the true malignant lesions.

Breast MRI background parenchymal enhancement (BPE) correlates with the risk of breast cancer

OBJECTIVES To investigate whether background parenchymal enhancement (BPE) and breast cancer would correlate searching for any significant difference of BPE pattern distribution in case of benign or malignant lesions. METHODS 386 patients, including 180 pre-menopausal (group 1) and 206 post-menopausal (group 2), underwent MR examination. Two radiologists evaluated MR images classifying normal BPE as minimal, mild, moderate or marked. The two groups of patients were subdivided into 3 categories based on MRI findings (negative, benign and malignant lesions). The distribution of BPE patterns within the two groups and within the three MR categories was calculated. The χ2 test was used to evaluate BPE type distribution in the three patient categories and any statistically significant correlation of BPE with lesion type was calculated. The Student t test was applied to search for any statistically significant difference between BPE type rates in group 1 and 2. RESULTS The χ2 test demonstrated a statistically significant difference in the distribution of BPE types in negative patients and benign lesions as compared with malignant ones (p<0.05). A significantly higher prevalence of moderate and marked BPE was found among malignant lesions (group 1: 32% and 42%, respectively; group 2: 31% and 46%, respectively) while a predominance of minimal and mild BPE among negative patients (group 1: 60% and 36%, respectively; group 2: 68% and 32%, respectively) and benign lesions (group 1: 54% and 38%, respectively; group 2: 75% and 17%, respectively) was found. The Student t test did not show a statistically significant difference between BPE type rates in group 1 and 2 (p>0.05). CONCLUSION Normal BPE could correlate with the risk of breast cancer being such BPE patterns as moderate and marked associated with patients with malignant lesions in both pre and post-menopausal women.

Multi-detector CT features of acute intestinal ischemia and their prognostic correlations.

Acute intestinal ischemia is an abdominal emergency occurring in nearly 1% of patients presenting with acute abdomen. The causes can be occlusive or non occlusive. Early diagnosis is important to improve survival rates. In most cases of late or missed diagnosis, the mortality rate from intestinal infarction is very high, with a reported value ranging from 60% to 90%. Multi-detector computed tomography (MDCT) is a fundamental imaging technique that must be promptly performed in all patients with suspected bowel ischemia. Thanks to the new dedicated reconstruction program, its diagnostic potential is much improved compared to the past and currently it is superior to that of any other noninvasive technique. The increased spatial and temporal resolution, high-quality multi-planar reconstructions, maximum intensity projections, vessel probe, surface-shaded volume rending and tissue transition projections make MDCT the gold standard for the diagnosis of intestinal ischemia, with reported sensitivity, specificity, positive and negative predictive values of 64%-93%, 92%-100%, 90%-100% and 94%-98%, respectively. MDCT contributes to appropriate treatment planning and provides important prognostic information thanks to its ability to define the nature and extent of the disease. The purpose of this review is to examine the diagnostic and prognostic role of MDCT in bowel ischemia with special regard to the state of art new reconstruction software.

MR evaluation of breast lesions obtained by diffusion-weighted imaging with background body signal suppression (DWIBS) and correlations with histological findings

OBJECTIVES Diffusion imaging represents a new imaging tool for the diagnosis of breast cancer. This study aims to investigate the role of diffusion-weighted MRI with background body signal suppression (DWIBS) for evaluating breast lesions. METHODS 90 patients were prospectively evaluated by MRI with STIR, TSE-T2, contrast enhanced THRIVE-T1 and DWIBS sequences. DWIBS were analyzed searching for the presence of breast lesions and calculating the ADC value. ADC values of ≤1.44×10(-3)mm(2)/s were considered suspicious for malignancy. This analysis was then compared with the histological findings. Sensitivity, specificity, diagnostic accuracy (DA), positive predictive value (PPV) and negative (NPV) were calculated. RESULTS In 53/90 (59%) patients, DWIBS indicated the presence of breast lesions, 16 (30%) with ADC values of >1.44 and 37 (70%) with ADC≤1.44. The comparison with histology showed 25 malignant and 28 benign lesions. DWIBS sequences obtained sensitivity, specificity, DA, PPV and NPV values of 100, 82, 87, 68 and 100%, respectively. CONCLUSION DWIBS can be proposed in the MRI breast protocol representing an accurate diagnostic complement.

Unenhanced breast MRI (STIR, T2-weighted TSE, DWIBS): An accurate and alternative strategy for detecting and differentiating breast lesions☆

PURPOSE To assess the role of STIR, T2-weighted TSE and DWIBS sequences for detecting and characterizing breast lesions and to compare unenhanced (UE)-MRI results with contrast-enhanced (CE)-MRI and histological findings, having the latter as the reference standard. MATERIALS AND METHODS Two hundred eighty consecutive patients (age range, 27-73 years; mean age±standard deviation (SD), 48.8±9.8years) underwent MR examination with a diagnostic protocol including STIR, T2-weighted TSE, THRIVE and DWIBS sequences. Two radiologists blinded to both dynamic sequences and histological findings evaluated in consensus STIR, T2-weighted TSE and DWIBS sequences and after two weeks CE-MRI images searching for breast lesions. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy for UE-MRI and CE-MRI were calculated. UE-MRI results were also compared with CE- MRI. RESULTS UE-MRI sequences obtained sensitivity, specificity, diagnostic accuracy, PPV and NPV values of 94%, 79%, 86%, 79% and 94%, respectively. CE-MRI sequences obtained sensitivity, specificity, diagnostic accuracy, PPV and NPV values of 98%, 83%, 90%, 84% and 98%, respectively. No statistically significant difference between UE-MRI and CE-MRI was found. CONCLUSION Breast UE-MRI could represent an accurate diagnostic tool and a valid alternative to CE-MRI for evaluating breast lesions. STIR and DWIBS sequences allow to detect breast lesions while T2-weighted TSE sequences and ADC values could be useful for lesion characterization.

Hepatic nodular regenerative lesions in patients with hereditary haemorrhagic telangiectasia: computed tomography and magnetic resonance findings

PurposeThis study was done to evaluate the prevalence of regenerative hepatic nodules in patients with hereditary haemorrhagic telangiectasia (HHT).Materials and methodsBetween February 2001 and December 2010, 171 consecutive HHT patients (95 men and 76 women) were studied with triphasic multidetector computed tomography (MDCT) in 91 cases, magnetic resonance imaging (MRI) in 34 cases and both in the remaining 46 cases. The presence of diffuse vascular abnormalities and focal liver lesions were recorded.ResultsHepatic arteriovenous malformations (HAVMs) were found in 126/171 (74%) patients. Arteriovenous shunts were found in 24/171 (14%) cases, arterioportal shunts in 52/171 (30%), mixed shunts in 26/171 (15%), telangiectases in 84/171 (49%) and transient hepatic attenuation differences (THADs) in 70/171 (41%). Hepatic nodular lesions were found in 6/171 (3.5%) patients (three men; three women). In 5/6 cases, vascular abnormalities were also evident. Two patients had a single lesion; four had multiple lesions. No lesion showed a central scar.ConclusionsHyperenhancing hepatic regenerative lesions have a high prevalence in HHT patients, representing the response of liver parenchyma to hypoperfusion caused by HAVMs. These lesions are often multiple and may lead to nodular regenerative hyperplasia.RiassuntoObiettivoScopo del presente lavoro è valutare la frequenza di lesioni nodulari rigenerative nei pazienti affetti da telangiectasia emorragica ereditaria (HHT).Materiali e metodiNel periodo compreso tra febbraio 2001 e dicembre 2010 sono stati arruolati consecutivamente 171 pazienti (95 uomini, 76 donne) affetti da HHT. La presenza di alterazioni epatiche è stata ricercata in 91 casi con TCMD trifasica (fase arteriosa precoce, tardiva e fase venosa) e in 34 con angio-risonanza magnetica (RM) dinamica, i rimanenti 46 pazienti sono stati sottoposti ad entrambi gli esami.RisultatiIn 126/171 (74%) pazienti sono state diagnosticate alterazioni vascolari epatiche costituite da fistole artero-venose (24/171, 14%), fistole artero-portali (52/171, 30%), fistole miste (26/171, 15%), telangiectasie (84/171, 49%) e disordini di perfuzione (THADs) (70/171, 41%). In 6/171 casi (3 donne e 3 uomini, 3,5%) sono state descritte lesioni nodulari epatiche ipervascolarizzate associate in 5 pazienti ad altre lesioni vascolari. Due pazienti erano portatori di una lesione singola mentre in quattro casi sono state dimostrate lesioni multiple. In nessun caso è stata riconosciuta una cicatrice centrale.ConclusioniLe lesioni epatiche rigenerative hanno un’elevata prevalenza nei pazienti affetti da HHT e costituiscono una risposta del fegato all’ipoperfusione determinata dagli shunt artero-venosi intraparenchimali. Tali lesioni si presentano spesso in forma multipla e possono determinare un quadro di iperplasia nodulare rigenerativa diffusa.

Preoperative local staging of colosigmoideal cancer: air versus water multidetector-row CT colonography

PurposeThe authors sought to evaluate the diagnostic accuracy of multidetector-row computed tomography (MDCT) performed with two different hypodense endoluminal contrast agents for the preoperative staging of colosigmoideal cancer.Materials and methodsSeventy consecutive patients with an endoscopically and histologically proven diagnosis of colosigmoideal cancer underwent MDCT examination. Thirty-five patients were evaluated with water MDCT colonography and the remaining 35 with air MDCT colonography. Patients were randomly assigned to the air or water groups for staging. Transverse images and multiplanar reconstructions (MPR) were retrospectively examined by two blinded expert radiologists in order to assess T and N parameters, and the results were compared with histological findings.ResultsThe overall diagnostic accuracy of MDCT was 68.6% for water and 62.8% for air colonography. In the evaluation of the T parameter, the accuracy values were 88.6% for water and 80% for air colonography. In staging of the N parameter, the accuracy values were 77.1% and 74.3% for water and air MDCT colonography, respectively.ConclusionsMDCT examination can be proposed for the local staging of colosigmoideal cancer. Water is more accurate than air in evaluation of the T parameter, whereas the kind of endoluminal contrast material does not influence the definition of the N parameter.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’accuratezza diagnostica della tomografia computerizzata multidetettore (TCMD) nella stadiazione preoperatoria del carcinoma del colon-sigma utilizzando due differenti mezzi di contrasto ipodensi endoluminali.Materiali e metodiSettanta pazienti consecutivi con diagnosi endoscopica ed istologica di carcinoma del colon-sigma sono stati sottoposti a TCMD. Trentacinque sono stati valutati mediante colonografia TC con acqua e i restanti trentacinque mediante colonografia TC con aria. I pazienti sono stati assegnati in maniera random ai gruppi di stadiazione con aria o acqua. Le immagini assiali e le ricostruzioni multiplanari (MPR) sono state esaminate in cieco retrospettivamente da due radiologi esperti al fine di determinare i parametri T e N ed i risultati sono stati confrontati con i reperti istologici.RisultatiL’accuratezza diagnostica complessiva della TCMD è risultata del 68,6% per la colonografia con acqua e del 62,8% per quella con aria. Nella valutazione del parametro T, i valori di accuratezza per la colonografia con acqua e aria sono risultati rispettivamente pari a 88,6% e 80%. Nella stadiazione del parametro N, sono stati ottenuti valori di accuratezza del 77,1% e 74,3% rispettivamente per la colonografia con acqua e aria.ConclusioniLa TCMD rappresenta una metodica proponibile per la stadiazione locoregionale del carcinoma del colon-sigma. L’impiego dell’acqua nella valutazione del parametro T risulta più accurata rispetto all’aria. Il tipo di mezzo di contrasto endoluminale non sembra influenzare la definizione del parametro N.

Effect of background parenchymal enhancement on breast cancer detection with magnetic resonance imaging

OBJECTIVE To investigate whether background parenchymal enhancement (BPE) may influence the sensitivity of dynamic contrast-enhanced magnetic resonance (DCE-MR) imaging in breast cancer detection. MATERIALS AND METHODS A total of 180 consecutive women with 194 breast cancers underwent MR imaging examination. Women were assigned to two different groups depending on the degree of BPE. Group 1 consisted of women with minimal or mild BPE and group 2 of women with moderate or marked BPE. The distributions of histotypes of tumors within the two groups were compared using the χ(2) test. Difference in sensitivities of DCE-MR imaging for tumor detection between the two groups was searched for using the Student t-test. RESULTS No differences in terms of distributions of histotypes of tumors between the two groups of women were found (P=0.5). The 11% difference in sensitivity of DCE-MR imaging for tumor detection between group 1 (91/92; 99%; 95% CI: 94-100%) and group 2 (90/102; 88%; 95% CI: 80-94%) was statistically significant (P=0.0058). CONCLUSION The sensitivity of DCE-MR imaging is significantly lower in women with moderate and marked BPE as compared with women with minimal and mild BPE regardless of cancer histotype. BPE could represent a limitation for breast MR imaging interpretation and should be indicated in MR imaging reports.