Pietro Valerio Foti

Pelvic floor imaging: comparison between magnetic resonance imaging and conventional defecography in studying outlet obstruction syndrome

PurposeThis study prospectively compared the diagnostic capabilities of magnetic resonance (MR) imaging with conventional defecography (CD) in outlet obstruction syndrome.Materials and methodsNineteen consecutive patients with clinical symptoms of outlet obstruction underwent pelvic MR examination. The MR imaging protocol included static T2-weighted fast spin-echo (FSE) images in the sagittal, axial and coronal planes; dynamic midsagittal T2-weighted single-shot (SS)-FSE and fast imaging employing steady-state acquisition (FIESTA) cine images during contraction, rest, straining and defecation. MR images (including and then excluding the evacuation phase) were compared with CD, which is considered the reference standard.ResultsComparison between CD and MR with evacuation phase (MRWEP) showed no significant differences in sphincter hypotonia, dyssynergia, rectocele or rectal prolapse and significant differences in descending perineum. Comparison between CD and MR without evacuation phase (MRWOEP) showed no significant differences in sphincter hypotonia, dyssynergia or enterocele but significant differences in rectocele, rectal prolapse and descending perineum. Comparison between MRWEP and MRWOEP showed no significant differences in sphincter hypotonia, dyssynergia, enterocele or descending perineum but significant differences in rectocele, rectal prolapse, peritoneocele, cervical cystoptosis and hysteroptosis.ConclusionsMR imaging provides morphological and functional study of pelvic floor structures and may offer an imaging tool complementary to CD in multicompartment evaluation of the pelvis. An evacuation phase is mandatory.RiassuntoObiettivoScopo del presente lavoro è stato confrontare prospettivamente le capacità diagnostiche della risonanza magnetica (RM) con quelle della defecografia tradizionale (DT) nello studio della sindrome da defecazione ostruita.Materiali e metodiDiciannove pazienti consecutivi con defecazione ostruita sono stati sottoposti ad RM della pelvi. Sono state acquisite sequenze statiche fast spin echo (FSE)-T2-pesate sui piani sagittale, assiale e coronale e sequenze dinamiche single shot fast spin echo (SSFSE) e fast imaging employing steady-state acquisition (FIESTA) sul piano sagittale mediano durante contrazione dello sfintere anale, riposo, ponzamento, defecazione. Le immagini RM (prima includendo, poi escludendo la fase di evacuazione) sono state confrontate con la DT considerata come standard di riferimento.RisultatiIl confronto DT vs RM con fase di evacuazione (RMCE) ha evidenziato differenze statisticamente non significative nell’ipotonia sfinteriale, dissinergia, rettocele, prolasso rettale, enterocele e differenze significative nel perineo discendente. Il confronto DT vs RM senza fase di evacuazione (RMSE) ha evidenziato differenze non significative nell’ipotonia sfinteriale, dissinergia, enterocele e differenze significative nel rettocele, prolasso rettale, perineo discendente. Il confronto RMCE vs RMSE ha evidenziato differenze non significative nell’ipotonia sfinteriale, dissinergia, enterocele, perineo discendente e differenze significative nel rettocele, prolasso rettale, peritoneocele, cervicocistoptosi, isteroptosi.ConclusioniLa RM consente di effettuare uno studio morfologico e funzionale del pavimento pelvico; può rappresentare un esame complementare alla DT nella valutazione multicompartimentale della pelvi. La fase di evacuazione è fondamentale.

Imaging findings of mucopolysaccharidoses: a pictorial review

IntroductionMucopolysaccharidosis (MPS) represent a heterogeneous group of inheritable lysosomal storage diseases in which the accumulation of undegraded glycosaminoglycans (GAGs) leads to progressive damage of affected tissues. The typical symptoms include organomegaly, dysostosis multiplex, mental retardation and developmental delay. Definitive diagnosis is usually possible through enzymatic assays of the defective enzyme in cultured fibroblasts or leukocytes.Imaging findingsRadiological and neuroradiological findings are reported. The most important neuroradiological features include abnormal signal intensity in the white matter, dilatation of periventricular spaces, widening of cortical sulci, brain atrophy, enlargement of extraventricular spaces and spinal cord compression. With reference to the skeletal system, most important radiological findings include multiplex dysostosis, which is represented by several bone malformations found in the skull, hands, legs, arms and column. The abnormal storage of GAGs leads to liver and spleen enlargement; it also damages cartilage layers and synovial recesses in the joints.ConclusionThe aim of this pictorial essay is to describe the imaging findings of MPS, represented by skeletal and neurological features; skeletal X-ray and MR allow an assessment of the severity of disease, to plan medical and surgical therapy and to evaluate response to treatment.Teaching Points• To describe the imaging findings common to different types of MPS.• To describe multiplex dysostosis encountered in the axial and appendicular skeleton.• To evaluate neuroradiological features of MPS, including brain abnormal signal intensity and atrophy.• To evaluate important otorhinolaryngological problems, such as otitis media and airways obstruction.

Evaluation of the biliary and pancreatic system with 2D SSFSE, breathhold 3D FRFSE and respiratory-triggered 3D FRFSE sequences.

PurposeThe authors compared biliary and pancreatic imaging obtained through 2D single-shot fast spin-echo (SSFSE), breath-hold 3D fast recovery fast spin-echo (FRFSE) and respiratory-triggered 3D FRFSE sequences.Materials and methodsA total of 106 magnetic resonance cholangiopancreatography (MRCP) examinations performed between December 2007 and September 2008 were evaluated with a comparison of 2D SSFSE (thin section and thick slab), breath-hold 3D FRFSE and respiratory-triggered 3D FRFSE sequences. The biliary tract was divided into seven segments: right hepatic duct, left hepatic duct, common hepatic duct, cystic duct, common bile duct, cystic duct junction and biliarypancreatic confluence. The main pancreatic duct was divided into three segments (head, body and tail). Visualisation of biliary variants was also compared. Two blinded radiologists evaluated segment visibility using a quantitative scale. The Student’s t test for paired samples was used for statistical analysis.ResultsCompared with 2D SSFSE, respiratory-triggered 3D FRFSE sequences showed better visibility of the right hepatic duct (p=0.0277), the cystic duct (p=0.0081), the cystic duct junction (p=0.0010), the biliary-pancreatic confluence (p=0.0334) and biliary variants (p=0.0198). In the comparison between breath-hold 3D FRFSE and 2D SSFSE, a significant statistical difference was found in visualisation of the cystic duct (p=0.027), the cystic duct junction (p=0.020), the biliary-pancreatic confluence (p=0.0338) and biliary variants (p=0.0311).ConclusionsThree-dimensional FRFSE offers a significant benefit over conventional 2D imaging.RiassuntoObiettivoScopo del nostro studio è stato confrontare l’imaging biliare e pancreatico mediante 2D single-shot fast spin-echo (SSFSE), 3D fast recovery fast spin-echo (FRFSE) breath-hold e 3D FRFSE triggerate.Materiali e metodiCentosei esami di colangiopancreatografia in risonanza magnetica (RM) — eseguiti tra dicembre 2007 e settembre 2008 — sono state analizzati confrontando SSFSE 2D (con spessore sottile e con slab), FRFSE 3D breath-hold e FRFSE 3D triggerate con il respiro. L’albero biliare è stato suddiviso in 7 segmenti: dotto destro, dotto sinistro, dotto epatico comune, dotto cistico, coledoco, inserzione cistico-coledocica e confluenza coledoco-pancreatica. Il dotto pancreatico è stato ripartito in 3 parti (testa, corpo e coda). È stata confrontata anche la visualizzazione di varianti biliari. Due radiologi in cieco hanno valutato la visibilità dei segmenti mediante una scala quantitativa; le analisi statistiche sono state effettuate mediante test t di Student per dati appaiati.RisultatiRispetto alle SSFSE 2D, FRFSE triggerate hanno evidenziato migliore visualizzazione dell’epatico destro (p=0,0277), del cistico (p=0,0081), della giunzione cistico-coledocica (p=0,0010) e delle varianti biliari (p=0,0198); nel confronto 3D FRFSE breath-hold versus SSFSE 2D, è stata rilevata differenza statisticamente significativa nella visualizzazione del cistico (p=0,027), del punto d’inserzione del cistico (p=0,020), della confluenza coledoco-pancreatica (p=0,0338) e delle varianti biliari (p=0,0311).ConclusioniFRFSE 3D rappresentano un importante valore aggiunto all’imaging convenzionale 2D.

MR imaging of ovarian masses: classification and differential diagnosis

AbstractObjectiveWe propose a Magnetic Resonance Imaging (MRI) guided approach to differential diagnosis of ovarian tumours based on morphological appearance.BackgroundCharacterization of ovarian lesions is of great importance in order to plan adequate therapeutic procedures, and may influence patient’s management. Optimal assessment of adnexal masses requires a multidisciplinary approach, based on physical examination, laboratory tests and imaging techniques. Primary ovarian tumours can be classified into three main categories according to tumour origin: epithelial, germ cell and sex cord-stromal tumours. Ovarian neoplasms may be benign, borderline or malignant. Using an imaging-guided approach based on morphological appearance, we classified adnexal masses into four main groups: unilocular cyst, multilocular cyst, cystic and solid, predominantly solid. We describe MR signal intensity features and enhancement behaviour of ovarian lesions using pathologically proven examples from our institution.ConclusionMRI is an essential problem-solving tool to determine the site of origin of a pelvic mass, to characterize an adnexal mass, and to detect local invasion. The main advantages of MRI are the high contrast resolution and lack of ionizing radiation exposure. Although different pathological conditions may show similar radiologic manifestations, radiologists should be aware of MRI features of ovarian lesions that may orientate differential diagnosis.Teaching Points• Diagnostic imaging plays a crucial role in detection, characterization and staging of adnexal masses. • Characterization of an ovarian lesion may influence patient’s management. • Different pathological conditions may have similar radiologic manifestations. • Non-neoplastic lesions should always be taken into consideration.

Locally advanced rectal cancer: Qualitative and quantitative evaluation of diffusion-weighted MR imaging in the response assessment after neoadjuvant chemo-radiotherapy

Purpose to investigate the added value of qualitative and quantitative evaluation of diffusion weighted (DW) magnetic resonance (MR) imaging in response assessment after neoadjuvant chemo-radiotherapy (CRT) in patients with locally advanced rectal cancer (LARC). Methods 31 patients with LARC (stage ≥ T3) were enrolled in the study. All patients underwent conventional MRI and DWI before starting therapy and after neoadjuvant CRT. All patients underwent surgery; pathologic staging represented the reference standard. For qualitative analysis, two radiologists retrospectively reviewed conventional MR images and the combined set of conventional and DW MR images and recorded their confidence level with respect to complete response (ypCR). For quantitative analysis, tumor’s apparent diffusion coefficient (ADC) values were measured at each examination. ADC pre-CRT, ADC post-CRT and Δ ADC post−ADC pre of the three groups of response (ypCR, partial response ypPR, stable disease ypSD) were compared. Receiver-operating characteristics (ROC) curve analysis was employed to investigate the discriminatory capability for ypCR, responders (ypCR, ypPR) and ypSD of each measure. Results addition of DWI to conventional T2-weighted sequences improved diagnostic performance of MRI in the evaluation of ypCR. A low tumor ADC value in the pre-CRT examination, a high ADC value in the post-CRT examination, a high Δ ADC post−ADC pre [>0.3 (×10−3 mm2/s)] were predictive of ypCR. Conclusions DW sequences improve MR capability to evaluate tumor response to CRT. Nevertheless, no functional MR technique alone seems accurate enough to safely select patients with ypCR.

Contrast-enhanced colour-Doppler sonography versus pH-metry in the diagnosis of gastro-oesophageal reflux in children

PurposeThe aim of this study was to evaluate the accuracy of contrast-enhanced colour-Doppler ultrasound (CDUS) in the diagnosis of gastro-oesophageal reflux in children.Materials and methodsOne hundred and twenty children (68 boys and 52 girls aged between 1 month and two years) with a clinical suspicion of gastro-oesophageal reflux (postprandial vomiting, weight loss, failure to thrive, anaemia, night-time coughing and crying, regurgitation, etc.) were studied by contrast-enhanced CDUS and subsequently by 24-hour pH-metry. Results of the two techniques were compared using the McNemar test.ResultsGastro-oesophageal reflux was detected on CDUS in 84 patients and with 24-h pH-metry in 86. In all cases of reflux, CDUS visualised the passage of contrast material from the stomach into the abdominal and middle and distal third of the thoracic oesophagus, enabling assessment of the segment of oesophagus involved by the reflux. Compared with pH-metry, CDUS had a sensitivity of 98% (p<0.0001 with McNemar’s test).ConclusionsIn consideration of the results obtained and particularly of the low level of invasiveness, contrast-enhanced CDUS could be used to monitor children undergoing medical or surgical treatment for the complications of gastro-oesophageal reflux disease.RiassuntoObiettivoLo scopo di questo lavoro è la valutazione dell’accuratezza diagnostica dell’eco-color Doppler con mezzo di contrasto nella diagnosi del reflusso gastroesofageo nel bambino.Materiali e metodiCentoventi bambini, 68 maschi e 52 femmine, con età compresa tra 1 mese e 2 anni, con sospetto di reflusso gastro-esofageo all’esame clinico (vomito post-prandiale, perdita di peso, ritardo di crescita, anemia, tosse e pianto notturno, rigurgiti, ecc.), sono stati sottoposti ad esame con eco-color Doppler con MdC e successivamente con pH-metria nelle 24 ore. Il confronto dei risultati è stato eseguito con il McNemar test.RisultatiIl reflusso gastro-esofageo è stato evidenziato in 84 pazienti con l’ecografia e in 86 con la pH-metria nelle 24 ore. Il color Doppler ha evidenziato in tutti i casi di reflusso il passaggio del MdC dallo stomaco nel tratto addominale e nel terzo medio e distale del tratto toracico dell’esofago permettendo la valutazione della porzione di esofago interessata dal reflusso. Confrontato con la pH-metria, l’esame ecografico ha dimostrato sensibilità del 98% (p<0,0001 con il McNemar test).ConclusioniIn base ai risultati ottenuti e soprattutto in virtù della scarsa invasività, la suddetta metodica ecografica potrebbe essere utilizzata nel monitoraggio dei bambini con malattia da reflusso gastro-esofageo sottoposti a terapia medica o chirurgica delle complicanze del reflusso gastro-esofageo.

Clinical and radiological features of extra-pulmonary sarcoidosis: a pictorial essay

AbstractThe aim of this manuscript is to describe radiological findings of extra-pulmonary sarcoidosis. Sarcoidosis is an immune-mediated systemic disease of unknown origin, characterized by non-caseating epitheliod granulomas. Ninety percent of patients show granulomas located in the lungs or in the related lymph nodes. However, lesions can affect any organ. Typical imaging features of liver and spleen sarcoidosis include visceromegaly, with multiple nodules hypodense on CT images and hypointense on T2-weighted MRI acquisitions. Main clinical and radiological manifestations of renal sarcoidosis are nephrolithiasis, nephrocalcinosis, and acute interstitial nephritis. Brain sarcoidosis shows multiple or solitary parenchymal nodules on MRI that enhance with a ring-like appearance after gadolinium. In spinal cord localization, MRI demonstrates enlargement and hyperintensity of spinal cord, with hypointense lesions on T2-weighted images. Skeletal involvement is mostly located in small bone, showing many lytic lesions; less frequently, bone lesions have a sclerotic appearance. Ocular involvement includes uveitis, conjunctivitis, optical nerve disease, chorioretinis. Erythema nodosum and lupus pernio represent the most common cutaneous manifestations encountered. Sarcoidosis in various organs can be very insidious for radiologists, showing different imaging features, often non-specific. Awareness of these imaging features helps radiologists to obtain the correct diagnosis.Teaching Points• Systemic sarcoidosis can exhibit abdominal, neural, skeletal, ocular, and cutaneous manifestations. • T2 signal intensity of hepatosplenic nodules may reflect the disease activity. • Heerfordt’s syndrome includes facial nerve palsy, fever, parotid swelling, and uveitis.• In the vertebrae, osteolytic and/or diffuse sclerotic lesions can be found. • Erythema nodosum and lupus pernio represent the most common cutaneous manifestations.

Diffusion weighted imaging and diffusion tensor imaging in the evaluation of transplanted kidneys

Objective The aim of this study is to investigate the relation between renal indexes and functional MRI in a population of kidney transplant recipients who underwent MR with diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI) of the transplanted graft. Method Study population included 40 patients with single kidney transplant. The patients were divided into 3 groups, on the basis of creatinine clearance (CrCl) values calculated using Cockcroft-Gault formula: group A, including patients with normal renal function (CrCl ≥ 60 mL/min); group B, which refers to patients with moderate renal impairment (CrCl > 30 but <60 mL/min); and, finally, group C, which means severe renal deterioration (CrCl ≤ 30 mL/min). All patients were investigated with a 1.5 Tesla MRI scanner, acquiring DWI and DTI sequences. A Mann–Whitney U test was adopted to compare apparent diffusion coefficients (ADCs) and fractional anisotropy (FA) measurements between groups. Receiver operating characteristic (ROC) curves were created for prediction of normal renal function (group A) and renal failure (group C). Pearson correlation was performed between renal clearance and functional imaging parameter (ADC and FA), obtained for cortical and medullar regions. Results Mann–Whitney U test revealed a highly significant difference (p < 0.01) between patients with low CrCl (group C) and normal CrCl (group A) considering both medullar ADC and FA and cortical ADC. Regarding contiguous groups, the difference between group B and C was highly significant (p < 0.01) for medullar ADC and significant (p < 0.05) for cortical ADC and medullar FA. No difference between these groups was found considering cortical FA. Analyzing groups A and B, we found a significant difference (p < 0.05) for medullar both ADC and FA, while no difference was found for cortical ADC and FA. Strongest Pearson correlation was found between CrCl and medullar ADC (r = 0.65). For predicting normal renal function or severe renal impairment, highest values of AUC were observed using medullar ADC cut-off values (respectively 0.885 and 0.871); medullar FA showed also high accuracy (respectively 0.831 and 0.853). Conclusions DWI and DTI are promising tools for non-invasive monitoring of renal function; medullar ADC proved to be the best parameter for renal function assessment.

The utilization of imaging features in the management of intraductal papillary mucinous neoplasms.

Intraductal papillary mucinous neoplasms (IPMNs) represent a group of cystic pancreatic neoplasms with large range of clinical behaviours, ranging from low-grade dysplasia or borderline lesions to invasive carcinomas. They can be grouped into lesions originating from the main pancreatic duct, main duct IPMNs (MD-IPMNs), and lesions which arise from secondary branches of parenchyma, denominated branch-duct IPMNs (BD-IPMNs). Management of these cystic lesions is essentially based on clinical and radiological features. The latter have been very well described in the last fifteen years, with many studies published in literature showing the main radiological features of IPMNs. Currently, the goal of imaging modalities is to identify “high-risk stigmata” or “worrisome feature” in the evaluation of pancreatic cysts. Marked dilatation of the main duct (>1 cm), large size (3–5 cm), and intramural nodules have been associated with increased risk of degeneration. BD-IPMNs could be observed as microcystic or macrocystic in appearance, with or without communication with main duct. Their imaging features are frequently overlapped with cystic neoplasms. The risk of progression for secondary IPMNs is lower, and subsequently an imaging based follow-up is very often proposed for these lesions.

ADAM 10 expression in primary uveal melanoma as prognostic factor for risk of metastasis.

Uveal melanoma is the most frequent primary intraocular neoplasm in adults. Although malignant melanoma may be located at any point in the uveal tract, the choroid and ciliary body are more frequent locations than the iris. In the present study, we examined ADAM10 expression levels in primary uveal melanoma both with and without metastasis, and we evaluated their association with other high risk characteristics for metastasis in order to assess if ADAM10 can be used to predict metastasis. This study included a total of 52 patients, 23 men and 29 women, with uveal melanoma. A significantly high expression of ADAM-10 was seen in patients with metastasis (11/13, 84.6%), but not in patients without metastasis (15/39, 38.5%). In conclusion we found that ADAM10 expression was associated with a more rapid metastatic progression confirming its role in uveal melanoma metastasis.