Nicola Settineri

Muscle Fat Fraction in Neuromuscular Disorders: Dual-Echo Dual-Flip-Angle Spoiled Gradient-Recalled MR Imaging Technique for Quantification—A Feasibility Study

PURPOSE To prospectively evaluate the muscle fat fraction (MFF) measured with dual-echo dual-flip-angle spoiled gradient-recalled acquisition in the steady state (SPGR) magnetic resonance (MR) imaging technique by using muscle biopsy as the reference standard. MATERIALS AND METHODS After ethics approval, written informed consent from all patients was obtained. Twenty-seven consecutive patients, evaluated at the Neuromuscular Disorders Center with a possible diagnosis of neuromuscular disorder, were prospectively studied with MR imaging of the lower extremities to quantify muscle fatty infiltration by means of MFF calculation. Spin-density- and T1-weighted fast SPGR in-phase and opposed-phase dual-echo sequences were performed, respectively, with 20° and 80° flip angles. Round regions of interest were drawn by consensus on selected MR sections corresponding to anticipated biopsy sites. These were marked on the patients skin with a pen by using the infrared spider light of the system, and subsequent muscle biopsy was performed. MR images with regions of interest were stored on a secondary console where the MFF calculation was performed by another radiologist blinded to the biopsy results. MFFs calculated with dual-echo dual-flip-angle SPGR MR imaging and biopsy were compared by using a paired t test, Pearson correlation coefficient, and Bland-Altman plots. P value of < .05 was considered to indicate a statistically significant difference. RESULTS The mean MFFs obtained with dual-echo dual-flip-angle SPGR MR imaging and biopsy were 20.3% (range, 1.7%-45.1%) and 20.6% (range, 3%-46.1%), respectively. The mean difference, standard deviation of the difference, and t value were -0.3, 1.3, and -1.3 (P > .2), respectively. The Pearson correlation coefficient was 0.995; with the Bland-Altman method, all data points were within the ± 2 SDs limits of agreement. CONCLUSION The results show that dual-echo dual-flip-angle SPGR MR imaging technique provides reliable calculation of MFF, consistent with biopsy measurements.

Dual-Source Dual-Energy CT Evaluation of Complex Cystic Renal Masses

OBJECTIVE The purpose of this study was to assess the value of dual-source dual-energy CT in the evaluation of complex cystic renal masses. SUBJECTS AND METHODS Seventy patients underwent contrast-enhanced dual-energy CT that included true unenhanced images acquired in single-energy mode, corticomedullary phase images acquired in dual-energy mode, and nephrographic phase images acquired in single-energy mode. Virtual unenhanced, blended weighted-average, and color-coded iodine overlay images were reconstructed. The acceptance level and image quality of virtual and true unenhanced images were evaluated. Contrast enhancement on both true unenhanced or blended weighted-average images and color-coded iodine overlay images was evaluated with both calculation in regions of interest and use of confidence level scales. Radiation dose parameters were estimated. RESULTS Virtual unenhanced images of 70 lesions (97.2%) and true unenhanced images of 72 lesions (100%) were judged acceptable (p = 0.5). The mean quality score of virtual unenhanced images was 2.0 ± 0.7 and of true unenhanced images was 1.5 ± 0.5 (p < 0.001). Mean contrast enhancement measured on true unenhanced and blended weighted-average images was 45.9 ± 15.9 HU (range, 21-78 HU) and on color-coded iodine overlay images was 47.3 ± 16.8 HU (range, 22-75 HU) with no significant differences. Enhancement was excluded on color-coded iodine overlay images with a significantly (p < 0.03) higher level of confidence than it was on true unenhanced and blended weighted-average images. The mean dose reduction with use of a combined dual- and single-energy dual-phase CT protocol was 29.1% ± 11.9% (p < 0.001). CONCLUSION Dual-source dual-energy CT is a reliable imaging technique in the evaluation of complex cystic renal masses. True unenhanced images can be replaced by virtual unenhanced images with considerable radiation dose reduction. The color-coded iodine overlay technique is a useful tool for both excluding and identifying endocystic enhancement.

Usefulness of power Doppler and contrast-enhanced sonography in the differentiation of hyperechoic renal masses

AbstractBackground: In a prospective study, we compared power Doppler with and without contrast medium in the depiction of vascularity for the characterization of hyperechoic renal lesions. Methods: Forty-one hyperechoic renal expansive lesions (29 benign, 12 malignant) in 32 patients were studied with power-Doppler ultrasonography before and after administration of an echo-enhancing agent (Levovist Schering AG, Berlin, Germany). Vascular architecture of the lesions was categorized into five different patterns. Results: Power Doppler ultrasonography showed vascular structures in 25 lesions. The study enhanced with Levovist showed vascularity in eight of 16 lesions not seen on the unenhanced study. The characterization of vascular patterns with unenhanced power Doppler ultrasonography improved diagnostic accuracy compared with gray-scale ultrasonography (59% vs. 32%). The combination of B mode and power Doppler produced even greater diagnostic accuracy (78%), independent of the administration of echo-enhancing agent. Levovist administration was useful in the differential diagnosis between pseudotumor and neoplasm. Conclusion: The use of songraphic contrast agent did not increase the diagnostic accuracy of power Doppler in the differential diagnosis of hyperechoic renal lesions but was advantageous for the characterization of suspected pseudomasses.

Usefulness of contrast-enhanced ultrasonography in the diagnosis of renal pseudotumors

Background: Within the term “pseudotumors” are grouped some renal anatomic variations that may simulate a focal renal lesion at ultrasonography. Our purpose was to assess the accuracy of contrast-enhanced ultrasonography (CEUS) using a second-generation contrast agent in the diagnosis of renal pseudotumors. Methods: We retrospectively retrieved CEUS examinations performed in 24 patients for characterization of suspected renal pseudotumor, in which conventional and power Doppler US study had been unable to confidently exclude a neoplasm. The considered criterion to define the diagnosis of renal pseudotumor was the demonstration of the same perfusion and reperfusion after microbubble breakage in both pseudotumor and surrounding parenchyma during early and late corticomedullary phase. In all patients, multiphase CT or dynamic MRI was available, representing a standard of reference for this study. In cases of CT or MRI diagnosis of renal lesion, final diagnoses were obtained with percutaneous renal biopsy or with surgery. Results: Contrast-enhanced ultrasonography diagnosis was concordant with MR or CT images in all cases. Conclusion: In our experience CEUS shows complete concordance with CT and MRI in the characterization of all 24 pseudotumors considered dubious at conventional and power Doppler US. The appropriate use of CEUS can reduce the need for contrast-enhanced CT or dynamic MRI in this item.

Combined magnetic resonance urography and targeted helical CT in patients with renal colic: a new approach to reduce delivered dose.

To determine whether magnetic resonance urography (MRU), obtained before helical computed tomography (CT) in patients with acute renal colic, can help delimit the obstructed area to be subsequently examined by a targeted CT scan, thus reducing the dose of radiation.

Induction chemotherapy with paclitaxel and cisplatin to concurrent radiotherapy and weekly paclitaxel in the treatment of loco-regionally advanced, stage IV (M0), head and neck squamous cell carcinoma. Mature results of a prospective study

Backgroundto evaluate activity and toxicity of a sequential treatment in advanced, non metastatic, mostly unresectable, head and neck squamous cell carcinoma.MethodsPatients with loco-regionally advanced or unresectable, head and neck cancer, were prospectively treated with 3 courses of induction chemotherapy followed by concurrent chemoradiation. Induction chemotherapy consisted of paclitaxel 175 mg/m2 day 1 and cisplatin 75 mg/m2 day 2, given every 3 weeks, to a total of three courses. Curative radiotherapy started 4 weeks after the last cycle of chemotherapy with the goal of delivering a total dose ≥ 66 Gy. During RT weekly paclitaxel (40 mg/m2) was administered.ResultsThe trial accrued 43 patients from January 1999 to December 2002. All patients received 3 courses of induction chemotherapy and the planned dose of radiotherapy. Thirty-eight patients were able to tolerate weekly paclitaxel during irradiation at least for 4 courses. After induction therapy there were 32 overall responses, 74.4% (23 partial and 9 complete); at completion of concomitant treatment overall responses were 42, 97.7% (20 partial and 22 complete). Median time to treatment failure was 20 months and the disease progression rate at 3 and 5 years was 33% and 23%, respectively. The median overall survival time was 24 months and 3 and 5 years overall survival rates were 37% and 26%, respectively. The major toxicity was mucositis.ConclusionsThis combined treatment was found to be feasible and active in advanced or unresectable, head and neck squamous cell carcinoma patients. Long-term results observed in this trial encourage to consider this approach in further investigation using newer radiation delivering technique and new molecularly agents.

WHAT IS THE BEST POSITION OF THE ARMS IN MANTLE FIELD FOR HODGKIN'S DISEASE?

PURPOSE To evaluate the best position of the arms in mantle field for Hodgkins disease. METHODS AND MATERIALS In 12 patients, with surgical clips placed at the time of an axillary dissection for breast cancer, the radiological projection of the clips according to three arm positions was prospectively evaluated: akimbo (A), extended (E), and up over the head (U). The surgical clips were arbitrarily separated into two groups: lower and upper. In each patient, the distance between the surgical clips and chest wall was measured, and the possibility of shielding the lungs and humeral heads was evaluated. RESULTS The mean displacement of the lower clips away from the chest wall when the patients were in A, E, and U positions was 2.5, 3.0, and 4.6 cm, respectively. The upper group clips showed a lower difference in distance from chest wall. In the U position, there was always a clip of the lower group that projected over the humeral head, making it impossible to block this structure. CONCLUSION In the A position, there is the possibility of blocking the humeral head, but it is necessary to irradiate more lung parenchyma. Type E treatment setup allows the shielding of both lung and humeral head, while maintaining adequate margins around the axillary nodes. In the U position, there is a greater possibility of shielding the lung parenchyma, but it is impossible to block the humeral heads.

Enlarged axillary nodes and position of the arms in axillary irradiation A computed tomography and magnetic resonance imaging evaluation

The purpose of this study was to evaluate the axillary node displacement away from chest wall and their anatomical location in relation to the humeral head, according to the position of the arms, when the axilla is the site of enlarged nodes. In 13 patients with enlarged axillary nodes, the anatomical span of the nodes according to two arms positions, akimbo (A) and up over the head (U), was prospectively evaluated using computed tomography (CT) and magnetic resonance imaging (MRI). The nodes were classified into two groups, i.e. the lower and upper groups. The mean distances of the lower node group from the chest wall when the patients were in A, and U positions were 3 cm and 6.4 cm, respectively (p=0.002). The upper group nodes showed a smaller difference in the distance from the chest wall: in A position, mean 2.1 cm; in U position 2.8 cm (p=0.03). In U position, there was always a node of the lower group that was displaced in front of the humeral head. This study demonstrates the displacement of enlarged axillary nodes according to the position of the arms. In patients with axillary node involvement, CT planning should be considered when they have their arms held up over their heads.

Muscle-invasive bladder cancer in elderly-unfit patients with concomitant illness: can a curative radiation therapy be delivered?

Aims and background There is no standard treatment for elderly-unfit patients with muscle-invasive bladder cancer. Pelvic irradiation alone is an usual approach in this instance, and some reports have demonstrated that curative radiotherapy is feasible in elderly patients. To our knowledge, no data exist about the feasibility of a curative treatment in elderly patients with concomitant illness and a Charlson Comorbidity Index (an index of comorbidity that includes age) greater than 2. The main purpose of the present study was to establish the feasibility of irradiation in a cohort of elderly patients in poor general condition. Methods The records of 45 elderly-unfit patients (median age, 75 years; range, 70-85), with a comorbid Charlson score >2, treated with curative dose, planned continuous-course, external beam radiotherapy for muscle-invasive bladder cancer were reviewed. The patients were treated to a median total dose of 60 Gy (range, 56–64), with an average fractional dose of 190 ± 10 cGy using megavoltage (6–15 MV). All patients were treated with radiation fields encompassing the bladder and grossly involved lymph nodes with a radiographic margin of at least 1.5 cm. Results No treatment-related mortality and clinically insignificant acute morbidity was recorded. No patient was hospitalized during or after the irradiation because of gastrointestinal or urogenital side effects. In one patient a week rest from therapy was necessary due a febrile status. Median survival was 21.5 months; overall 3- and 5-year survival was 36% and 19.5%, respectively. Conclusions Elderly-unfit patients with comorbidities and >70 years of age can be submitted to radical pelvic irradiation. The results observed in this retrospective analysis have encouraged us to use non-palliative radiotherapy doses in these patients with muscle-invasive bladder cancer.

Induction Chemotherapy to Weekly Paclitaxel Concurrent with Curative Radiotherapy in Stage IV (M0) Unresectable Head and Neck Squamous Cell Carcinoma: a Dose Escalation Study

Abstract The purpose was to determine the maximum tolerated dose (MTD) of weekly paclitaxel with concurrent, daily irradiation in patients with unresectable head and neck squamous cell carcinoma previously submitted to induction chemotherapy. Patients with stage IV, and unresectable tumor and/or node/s were enrolled. Nine male patients were submitted to a course of paclitaxel 175 mg/m2 day 1 and cis-platin 75 mg/m2 day 2 given every 3 weeks for three courses. Curative radiothera-py (RT) started 3 weeks after the last cycle of chemotherapy with the goal of deliv-ering a total dose of 66-70 Gy. During RT weekly paclitaxel was administered for 6 courses if feasible; paclitaxel was given according to a dose escalation schema in cohorts of three patients. Dose level A, 30 mg/m2; dose level B, 40 mg/m2; dose level C, 50 mg/m2. During weekly paclitaxel the major toxicity was mucositis that required a treatment break in two of three patients in dose level C; mucositis grade 4 required interruption of paclitaxel administration in all these patients. RT can be given in a continuous fashion with weekly paclitaxel after induction chemotherapy. The MTD of weekly paclitaxel was 40 mg/m2.