Michele Scialpi

Gastrointestinal Disorders in Elderly Patients

Gastrointestinal disorders are common in elderly patients, and the clinical presentation, complications, and management may differ from those in younger patient. Most impairment occurs in the proximal and distal tract of the gastrointestinal system. Swallowing abnormalities with a wide span of symptoms and pelvic floor pathologies involving all the pelvic compartments are common. Acute abdomen, often from small bowel obstruction or mesenteric ischemia, can pose a diagnostic challenge, because a mild clinical presentation may hide serious visceral involvement. In this setting, the radiologist often is asked to suggest the appropriate management options and to guide the management.

Contrast enhanced ultrasound (CEUS) in blunt abdominal trauma

In the assessment of polytrauma patient, an accurate diagnostic study protocol with high sensitivity and specificity is necessary. Computed Tomography (CT) is the standard reference in the emergency for evaluating the patients with abdominal trauma. Ultrasonography (US) has a high sensitivity in detecting free fluid in the peritoneum, but it does not show as much sensitivity for traumatic parenchymal lesions. The use of Contrast-Enhanced Ultrasound (CEUS) improves the accuracy of the method in the diagnosis and assessment of the extent of parenchymal lesions. Although the CEUS is not feasible as a method of first level in the diagnosis and management of the polytrauma patient, it can be used in the follow-up of traumatic injuries of abdominal parenchymal organs (liver, spleen and kidneys), especially in young people or children.

Accuracy of needle biopsy of breast lesions visible on ultrasound: audit of fine needle versus core needle biopsy in 3233 consecutive samplings with ascertained outcomes.

INTRODUCTION Core needle biopsy (CNB) has progressively replaced fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions. Less information is available on how these tests perform for biopsy of ultrasound (US) visible breast lesions. This study examines the outcomes of CNB and FNAC in a large series ascertained with surgical histology or clinical-imaging follow-up. MATERIALS AND METHODS Retrospective five-year audit of 3233 consecutive US-guided needle samplings of solid breast lesions, from self-referred symptomatic or asymptomatic subjects, performed by six radiologists in the same time-frame (2003-2006): 1950 FNAC and 1283 CNB. The probability of undergoing CNB as a first test instead of FNAC was evaluated using logistic regression. Accuracy and inadequacy were calculated for each of CNB and FNAC performed as first test. Accuracy measures included equivocal or borderline/atypical lesions as positive results. RESULTS The probability of CNB as a first test instead of FNAC increased significantly over time, when there was a pre-test higher level of suspicion, in younger (relative to older) women, with increasing lesion size on imaging, and for palpable (relative to impalpable) lesions. Inadequacy rate was lower for CNB (B1 = 6.9%) than for FNAC (C1 = 17.7%), p < 0.001, and specifically in malignant lesions (B1 = 0.9% vs. C1 = 4.5%; p < 0.001). False negative rate was equally low for both CNB and FNAC (1.7% each test). CNB performed significantly better than FNAC for absolute sensitivity (93.1% vs. 74.4%; p < 0.001) and complete sensitivity (97.4% vs. 93.8%; p = 0.001), however specificity was lower for CNB than FNAC (88.3% vs. 96.4%; p < 0.001). Absolute diagnostic accuracy was higher for CNB than FNAC (84.5% vs. 71.9; p < 0.001) while FNAC performed better than CNB for complete diagnostic accuracy (95.4% vs. 93.2; p < 0.008). In the small subgroup assessed with CNB after an inconclusive initial FNAC (231 cases) there was improved complete sensitivity (from 93.8% to 97.0%) however this also increased costs. CONCLUSION FNAC and CNB were generally performed in different patients, thus our study reported indirect comparisons of these tests. Although FNAC performed well (except for relatively high inadequacy), CNB had significantly better performance based on measures of sensitivity, but this was associated with lower specificity for CNB relative to FNAC. Overall, CNB is the more reliable biopsy method for sonographically-visible lesions; where FNAC is used as the first-line test, inadequate or inconclusive FNAC can be largely resolved by using repeat sampling with CNB.

Oncocytic sialolipoma of the submandibular gland with sebaceous differentiation: A new pathological entity

CASE REPORT We report the case of an oncocytic sialolipoma of the submandibular gland with sebaceous differentiation in a 73-year-old man. The initial symptom was a right submandibular painless mass. Ultrasonography showed a hypoechoic oval mass posterior to the submandibular gland. The tumorectomy was performed with preservation of the salivary gland. The tumor was composed of mature adipose tissue surrounded by a thin fibrous capsule, multiple nodules of oncocytes, normal ductal-acinar units with focal ductal sebaceous differentiation. DISCUSSION We reviewed literature of the reported cases of mixed tumors of the salivary glands composed of mature adipose tissue with oncocytosis, salivary ducts, and acini with sebaceous differentiation. CONCLUSIONS Sialolipoma and lipoadenoma with or without oncocytosis and/or sebaceous differentiation should be considered organ-specific tumors with a distinct histological appearance and specific terminology.

Pulmonary congenital cystic disease in adults. Spiral computed tomography findings with pathologic correlation and management

PurposeThe aim of this study was to assess the computed tomography (CT) features of intrapulmonary congenital cystic diseases in adults and to correlate the imaging features with the pathological findings, with emphasis on the oncogenic potential of the lesions.Materials and methodsWe retrospectively reviewed the CT scans in three institutions from August 1996 to December 2008, of nine patients (six men, three women; mean age 48.6 years; range 26–75 years) who had histological diagnosis of pulmonary cystic disease after surgery. Six patients had a diagnosis of intrapulmonary bronchogenic cyst (IBC), and three had a type-I cystic adenomatoid malformation (CAM). In one case, intralobar sequestration (ILS) was associated with type-I CAM.ResultsThree patients were symptomatic and six were asymptomatic. On CT scans, IBCs showed homogeneous fluid attenuation (n=2), air-fluid level (n=2), air attenuation (n=1) or soft-tissue attenuation (n=1). The surrounding lung tissue showed areas of band-like linear attenuation in three IBCs, atelectasia in two and mucocele-like areas in one. On CT, type-I CAM appeared as a unilocular cystic lesion with air-fluid level (n=1) or air content (n=1). Both cases had thin walls surrounded by normal lung parenchyma. ILS appeared as a fluid-filled cyst with afferent and efferent vessels. Of the six IBCs, one occurred in the upper right lobe, two in the middle lobe and three in the lower right lobe. Of the three type-I CAMs, one was in the upper left lobe and one in the middle lobe. The type-I CAM associated with ILS was located in the left lower lobe.ConclusionsThe similar CT patterns preclude differentiation between IBC and type-I CAM. Surgical resection of all intrapulmonary cystic lesions detected in adults is mandatory because type-I CAM is a precursor of mucinous bronchioloalveolar carcinoma.RiassuntoObiettivoScopo di questo lavoro è stato valutare con tomografia computerizzata (TC) gli aspetti semeiologici delle malattie cistiche congenite intrapolmonari nell’adulto e correlarle con i reperti patologici, in riferimento al potenziale oncogenetico di tali lesioni.Materiali e metodiAbbiamo analizzato retrospettivamente gli esami TC di tre centri, da agosto 1996 a dicembre 2008, relativi a nove pazienti (sei maschi e tre femmine, età media 48,6 anni, range compreso tra 26-75 anni) trattati chirurgicamente per patologia cistica polmonare, in cui l’esame istologico del pezzo operatorio ha consentito di ottenere la diagnosi definitiva: in sei pazienti cisti broncogena intrapolmonare (CBI) e in tre malformazione adenomatoide cistica (MAC) di tipo I, associata in un caso a sequestro polmonare intralobare (SPI).RisultatiTre pazienti erano sintomatici e sei asintomatici. All’esame TC le CBI si presentavano: in due casi come lesioni completamente liquide, in due casi con livello idroaereo contestuale, in un caso come una formazione completamente ripiena di aria e in un caso come una formazione omogenea rispetto alla densità dei tessuti molli. Nel parenchima contiguo alle CBI erano presenti bande lineari di fibrosi in tre casi, atelettasia in due e lesione simile a mucocele in un caso. Le MAC di tipo I si presentavano una come lesione cistica uniloculata con livello fluido, e l’altra a contenuto aereo; entrambe erano delimitate da una parete sottile con parenchima adiacente normale. La MAC associata a SPI appariva come cisti completamente ripiena di liquido con un arteria bronchiale ectasica afferente ed una vena efferente. Delle sei CBI, una era localizzata nel lobo superiore di destra, due nel lobo medio, e tre in quello inferiore di destra. Le tre MAC di tipo I erano localizzate nel lobo superiore di sinistra, nel lobo medio e quella associata a SPI, nel lobo inferiore sinistro.ConclusioniL’aspetto TC analogo tra CBI e MAC di tipo I non consente una diagnosi differenziale tra queste due lesioni. Nell’adulto è sempre raccomandabile la resezione chirurgica di tutte le lesioni intrapolmonari cistiche poiché la MAC di tipo I è il precursore del carcinoma mucinoso bronchiolo-alveolare.

Pancreatic tumors imaging: An update

Currently, ultrasound (US), computed tomography (CT) and Magnetic Resonance imaging (MRI) represent the mainstay in the evaluation of pancreatic solid and cystic tumors affecting pancreas in 80-85% and 10-15% of the cases respectively. Integration of US, CT or MR imaging is essential for an accurate assessment of pancreatic parenchyma, ducts and adjacent soft tissues in order to detect and to stage the tumor, to differentiate solid from cystic lesions and to establish an appropriate treatment. The purpose of this review is to provide an overview of pancreatic tumors and the role of imaging in their diagnosis and management. In order to a prompt and accurate diagnosis and appropriate management of pancreatic lesions, it is crucial for radiologists to know the key findings of the most frequent tumors of the pancreas and the current role of imaging modalities. A multimodality approach is often helpful. If multidetector-row CT (MDCT) is the preferred initial imaging modality in patients with clinical suspicion for pancreatic cancer, multiparametric MRI provides essential information for the detection and characterization of a wide variety of pancreatic lesions and can be used as a problem-solving tool at diagnosis and during follow-up.

Thoracic CT findings at hypovolemic shock

Purpose: To describe and discuss the thoracic CT features of hypovolemic shock. Material and Methods: From a group of 18 patients with signs of hypovolemia on contrast-enhanced abdominal CT, 11 were selected for our study as having also undergone a complete chest examination. Pulse rate, blood pressure, trauma score value, Glasgow coma scale value, surgical result, and final outcome were retrospectively evaluated. The CT features analyzed were: decreased cardiac volume, reduced caliber of the thoracic aorta, aortic branches and caval venous system, increased enhancement of the aorta, and increased enhancement of the pulmonary collapses/contusions. Results: All 11 subjects presented severe injuries and hemodynamic instability; 7 were stable enough to undergo surgery; only 1 of the 11 survived. Two patients showed none of the features of thoracic hypovolemia. All the other patients presented at least two signs: reduced caliber of the thoracic aorta in 7 cases; decreased volume of the cardiac chambers and increased aortic enhancement in 6; decreased caliber of the aortic vessels in 4; decreased caliber of the caval veins in 3; and increased enhancement of the pulmonary collapses/contusions in 3. Conclusions: In patients with hypovolemia, CT may show several thoracic findings in addition to abdominal ones. Knowledge of these features is important for distinguishing them from traumatic injuries.

Three–dimensional analysis of pulmonary nodules by MSCT with Advanced Lung Analysis (ALA1) software

Purpose.The purpose of this study was to test the reproducibility of the three–dimensional (3D) Advanced Lung Analysis software (3D–ALA, GE Healthcare) in the estimation of pulmonary nodule volume.Materials and methods.We retrospectively reviewed the unenhanced multislice CT scans (Lightspeed Pro 16 GE) of 77 patients with a solitary pulmonary nodule (n=71) or metastatic pulmonary disease (n=6). A total of 103 pulmonary nodules (19 well–circumscribed, 45 juxtavascular and 39 juxtapleural) were analysed grouped into five classes based on diameter: <5 mm, 10 nodules (9.7%); ≥5 to <10 mm, 25 nodules (24.2%); ≥10 mm to <15 mm, 41 nodules (39.8%); ≥ 5 to <18 mm, 14 nodules (13.6% ); ≥ 8 to <30 mm, 13 nodules (12.62%). The following acquisition parameters were used: slice thickness 0.625 mm, reconstruction interval 0.4 mm, pitch 0.562:1, 140 kV, 300 mAs, field of view 13 cm, bone kernel. For each of the 103 nodules three, 3D volume measurements were obtained by the 3D–ALA software. The reproducibility of nodule segmentation was evaluated according to a visual score (1=optimal, ≥95%; 2=fair, 90–95%; 3=poor, ≤90%) by three observers working in consensus. The reproducibility of volume estimation was evaluated by comparing all 3D volume measurements and all segmentations obtained for each pulmonary nodule using the ANOVA test.Results.ALA–1 software allowed segmentation in all nodules (type 1 segmentation n=43, type 2 n=35, type 3 segmentation n=25). ALA–1 provided an identical 3D volume measurement in 62 nodules: [16 out of 19 well circumscribed (84.2%), 31 out of 45 juxtavascular (68.8%), 15 out of 39 juxtapleural (38.4%)]. Repeatability of 3D volume measurement was not possible in 41 out of 103 nodules [3 out of 19 (15.7%) well–circumscribed, 14 out of 45 (31.1%) juxtavascular, 24 out of 39 (61.5%) juxtapleural]. Among the 41 nodules with nonrepeatable 3D volume measurement, segmentation was scored as 1 in 2 out of 41 (4.8%), as 2 in 15 out of 41 (36.5%) and as 3 in 24 out of 41 (58.5%). The difference between the mean volume on three measurements and each type of nodule was not statistically significant (p>0.05).Conclusions.Three–dimensional volume measurement with ALARiassunto 1 software is reproducible for all nodules as regards dimension and site. ALA–1 software provided a good and reproducible volume measurement in well–circumscribed and most juxtavascular nodules. Volumetric evaluation and reproducibility of volume estimation in juxtapleural pulmonary nodules, particularly those adjacent to diaphragmatic pleura, is inadequate, and software improvement is needed.

Lesion volume predicts prostate cancer risk and aggressiveness: validation of its value alone and matched with prostate imaging reporting and data system score.

To demonstrate the association between magnetic resonance imaging (MRI) estimated lesion volume (LV), prostate cancer detection and tumour clinical significance, evaluating this variable alone and matched with Prostate Imaging Reporting and Data System version 2 (PI‐RADS v2) score.

Small (≤2 cm) atypical hepatic haemangiomas in the non-cirrhotic patient: pattern-based classification scheme for enhancement at triple-phase helical CT

PurposeThe aim of this study was to determine by triplephase helical computed tomography (CT) the appearance of atypical small (≤2 cm) hepatic haemangiomas (HHs) in the non-cirrhotic patient.Materials and methodsWe retrospectively reviewed the hepatic arterial-dominant phase (HAP), portal venous phase (PVP) and delayed-phase (DP) helical CT images of 47 patients with 52 atypical small (≤2cm) HHs associated with 34 typical small HHs. Images were assessed to identify the patterns of enhancement of atypical HHs and correlate their appearance with that of typical small HHs in the delayed phase. Interobserver variability and kappa value were calculated. Statistical significance was calculated by the Fisher exact test.ResultsThe 52 atypical small HHs were categorised as follows: type 1a (hyperattenuating in the HAP, n=17), type 1b [hyperattenuating with transient hepatic attenuation difference (THAD) around the lesion in the HAP, n=12], type 2a (homogeneously hypoattenuating in the HAP or PVP, n=9), type 2b (hypoattenuating with “bright-dot” sign in the HAP or PVP, n=13) and type 3 (hypoattenuating with central enhancing area, n=1). Interobserver agreement was perfect for HHs of types 1a, 1b, 2a and 3. On DP images, the appearance of atypical small HHs was identical to that of typical small HHs in all cases (p<0.0001), with lesions showing homogeneous isoattenuation to the aorta or liver parenchyma without peripheral capsule.ConclusionsTriple-phase helical CT scans can distinguish several types of atypical small HHs. The demonstration of patterns similar to those of typical forms on DP CT is fundamental for the diagnosis.RiassuntoObiettivoDeterminare mediante tomografia computerizzata (TC) spirale trifasica l’aspetto degli emangiomi epatici (EE) atipici di piccole dimensioni (≤2 cm) in pazienti con fegato non-cirrotico.Materiali e metodiSono stati valutati retrospettivamente gli esami TC trifasici in fase dominante-arteriosa (FA), fase venosa portale (FVP) e fase tardiva (FT), di 47 pazienti con 52 emangiomi epatici (EE) atipici di piccole dimensioni (≤2 cm) associati a 34 EE tipici piccoli. Le immagini sono state esaminate al fine di individuare i patterns di enhancement degli EE atipici e correlare in FT il loro aspetto con quello degli EE piccoli tipici. Sono state calcolate la variabilita interosservatore e le differenze statistiche mediante il test esatto di Fisher.RisultatiI 52 EE atipici di piccole dimensioni erano così distribuiti: tipo 1a EE iperdenso in FA (n=17), tipo 1b EE iperdenso con transient hepatic attenuation difference (THAD) in FA (n=12), tipo 2a EE ipodenso in FA o FVP (n=9), tipo 2b EE ipodenso con puntiforme/i iperdensita periferica in FA o FVP (n=13), e tipo 3 EE ipodenso con iperdensità centrale ad enhancement centrifugo in FVP (n=1). È stata riscontrata completa concordanza tra i tre osservatori relativamente agli EE di tipo 1a, 1b, 2a, e 3. In FT l’aspetto degli EE atipici di piccole dimensioni (isodensità rispetto all’aorta o al parenchima epatico con assenza di capsula periferica) è risultato sovrapponibile a quello degli EE tipici di piccole dimensioni (p<0,0001).ConclusioniLa TC trifasica consente di distinguere diverse forme di EE atipici di piccole dimensioni che in FT presentano aspetto analogo alle forme tipiche di piccole dimensioni.