Renato Farina

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.

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.

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.

Functional study of the transplanted kidney with power Doppler US and time/intensity curves

Purpose.Power Doppler ultrasound (US) with time-intensity curves was used to study renal graft function both in the absence of disease and with complications (acute tubular necrosis and chronic rejection) in an attempt to identify pathognomonic patterns. Time-intensity curves allow representation of the kidneys’ wash-in and wash-out phases after intravenous administration of sonographic contrast material.Materials and methods.Fifty-six asymptomatic renal transplant patients (36 men and 20 women), 19 of whom had altered creatinine clearance levels, were studied by power Doppler US with time-intensity curves followed by biopsy. Ten asymptomatic patients with normal creatinine clearance levels were used as controls.Results.Time-intensity curve analysis enabled identification of three groups of patients: group A, consisting of 27 patients showing peak enhancement between 50 and 65 s from intravenous administration of contrast material; group B, consisting of 16 patients with peak enhancement between 135 and 235 s; group C, consisting of three patients with peak enhancement between 100 and 130 s.Conclusions.Data showed significant variations according to renal graft function (no abnormality, acute tubular necrosis or chronic rejection). Although confirmation by a larger series is required, our findings appear to indicate pathognomonic patterns in patients with chronic rejection and acute tubular necrosis.

Non-neoplastic diseases of the fallopian tube: MR imaging with emphasis on diffusion-weighted imaging

AbstractObjectiveWe illustrate the magnetic resonance imaging (MRI) features of non-neoplastic tubaric conditions.BackgroundA variety of pathologic non-neoplastic conditions may affect the fallopian tubes. Knowledge of their imaging appearance is important for correct diagnosis. With recent advances in MRI, along with conventional MR sequences, diffusion-weighted imaging (DWI) sequences are available and may improve lesion characterization by discriminating the nature of the content of the dilated tube. Tubal fluid with low signal intensity on T1-weighted images, high signal intensity on T2-weighted images and no restricted diffusion on DWI is indicative of hydrosalpinx. Content with high signal intensity on T1-weighted images and restricted diffusion on DWI is suggestive of hematosalpinx associated with endometriosis or tubal pregnancy. A dilated tube with variable or heterogeneous signal intensity content on conventional MR sequences and restricted diffusion on DWI may suggest a pyosalpinx or tubo-ovarian abscess. We describe morphological characteristics, MR signal intensity features, enhancement behaviour and possible differential diagnosis of each lesion.ConclusionMRI is the method of choice to study adnexal pelvic masses. Qualitative and quantitative functional imaging with DWI can be of help in characterization of tubaric diseases, provided that findings are interpreted in conjunction with those obtained with conventional MRI sequences.Teaching Points• Nondilated fallopian tubes are not usually seen on MR images. • MRI is the method of choice to characterize and localize utero-adnexal masses. • MRI allows characterization of lesions through evaluation of the fluid content’s signal intensity. • DWI in conjunction with conventional MRI sequences may improve tissue characterization. • Pelvic inflammatory disease is the most common tubal pathology.

Power Doppler ultrasonography with time-signal intensity curves in monitoring hepatocellular carcinoma and liver metastases after intralesional therapy.

PurposeAnalysis of time-intensity curves allows evaluation of the patterns of lesion enhancement before and after treatment. The aim of this study was to evaluate the diagnostic accuracy of time-intensity curves in monitoring intralesional therapy of focal hepatic lesions.Materials and methodsTwenty patients underwent intralesional therapy with either radiofrequency thermal ablation or percutaneous ethanol injection. Contrast-enhanced power Doppler ultrasound with analysis of timeintensity curves was performed one day before and one day after treatment. Targeted biopsy was then obtained to confirm the imaging findings.ResultsBefore treatment, all lesions showed time-intensity curves characterised by high peaks of signal intensity and plateaus. Complete tumour necrosis, confirmed by targeted biopsy, was observed in patients showing no intralesional flow signals and time-intensity curves with low peak of signal intensity and absence of plateau after treatment. Biopsy confirmed the presence of residual neoplastic tissue in one patient exhibiting perilesional vascularity, absence of intralesional flow signals, and a time-intensity curve with high peak of signal intensity and plateau.ConclusionsAccording to our findings, time-intensity curves characterised by high peak of signal intensity and plateau might reflect the presence of perilesional or intralesional neoplastic tissue and provide important information on the effectiveness of the treatment.RiassuntoObiettivoObiettivo di questo lavoro è la valutazione dell’accuratezza diagnostica delle curve intensità/tempo nel monitoraggio del trattamento intralesionale delle lesioni focali epatiche. Le curve intensità/tempo ci permettono di studiare la dinamica di enhancement delle lesioni prima e dopo il trattamento intralesionale.Materiali e metodiVenti pazienti sono stati sottoposti a trattamento intralesionale con termoablazione mediante radiofrequenza o alcoolizzazione percutanea. Prima del trattamento e dopo 1 giorno è stato eseguito il controllo ecografico con power Doppler e curve intensità/tempo. Per verificare i dati ottenuti è stata eseguita la biopsia mirata.RisultatiPrima dei trattamenti tutte le lesioni presentavano curve intensità/tempo con elevato picco di intensità e presenza di plateau. Dopo il trattamento, nei pazienti che presentavano assenza di segnali vascolari intralesionali, curve con basso picco di intensità e assenza di plateau, la biopsia mirata confermava la necrosi completa. In un paziente che presentava, dopo il trattamento, vascolarizzazione perilesionale, assenza di segnali vascolari intralesionali e curva intensità/tempo con elevato picco di intensità e plateau, la biopsia confermava la persistenza di tessuto neoplastico.ConclusioniIn base ai risultati ottenuti, le curve con elevato picco di intensità e presenza di plateau, potrebbero rappresentare pattern del tessuto neoplastico intra o perilesionale e fornire quindi importanti informazioni sull’efficacia del trattamento.

Endometrial carcinoma: MR staging and causes of error

This study was undertaken to prospectively determine the diagnostic capabilities of magnetic resonance (MR) imaging in detecting myometrial and cervical invasion and lymph node involvement in endometrial carcinoma and to identify the causes of errors in staging endometrial carcinoma.Materials and methodsTwenty consecutive patients with a histological diagnosis of endometrial carcinoma underwent preoperative MR imaging. MR findings were compared with surgical staging, considered as the standard of reference.ResultsIn assessing myometrial invasion, MR imaging showed 70% accuracy, 80% sensitivity, 40% specificity, 80% positive predictive value (PPV), and 40% negative predictive value (NPV). In detecting cervical invasion, MR imaging had 95% accuracy, 100% sensitivity, 94.4% specificity, 66.7% PPV, and 100% NPV. In evaluating lymph node involvement, MR imaging showed 100% accuracy, sensitivity, specificity, PPV and NPV. Errors in evaluating myometrial invasion were caused by polypoid tumour, adenomyosis and leiomyomas, whereas those in evaluating cervical invasion were caused by dilatation and curettage.ConclusionsMR imaging is a reliable technique for preoperative evaluation of endometrial carcinoma. Its main limitation is differentiating between stage IA and IB carcinomas, which is not highly important for surgical planning. Cooperation between the gynaecologist and radiologist is mandatory to avoid staging errors.RiassuntoObiettivoScopo del presente lavoro è stato determinare prospettivamente le capacità diagnostiche della risonanza magnetica (RM) nel valutare l’invasione del miometrio, della cervice ed il coinvolgimento linfonodale nel carcinoma dell’endometrio ed identificare le cause di errore nella stadiazione RM.Materiali e metodiVenti pazienti consecutive con diagnosi istologica di carcinoma dell’endometrio sono state sottoposte ad esame RM preoperatorio. I reperti RM sono stati confrontati con la stadiazione chirurgica considerata come standard di riferimento.RisultatiNel valutare l’invasione del miometrio la RM ha mostrato accuratezza del 70%, sensibilità dell’80%, specificità del 40%, valore predittivo positivo (VPP) dell’80%, valore predittivo negativo (VPN) del 40%. Nell’identificare l’infiltrazione della cervice la RM ha mostrato accuratezza del 95%, sensibilità del 100%, specificità del 94,4%, VPP del 66,7%, VPN del 100%. Nel valutare il coinvolgimento linfonodale la RM ha mostrato accuratezza, sensibilità, specificità, VPP e VPN del 100%. Le cause di errore nella valutazione del miometrio sono state: tumore polipoide, adenomiosi, leiomiomi; nella valutazione della cervice: raschiamento.ConclusioniLa RM è una tecnica affidabile nella valutazione preoperatoria del carcinoma dell’endometrio; il suo limite principale è rappresentato dalla distinzione fra stadio IA e IB, poco influente sulla strategia chirurgica. La collaborazione fra clinico e radiologo è fondamentale per evitare errori di stadiazione.

Endometriosis: clinical features, MR imaging findings and pathologic correlation

ObjectiveWe illustrate the magnetic resonance imaging (MRI) features of endometriosis.BackgroundEndometriosis is a chronic gynaecological condition affecting women of reproductive age and may cause pelvic pain and infertility. It is characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus and includes three different manifestations: ovarian endometriomas, peritoneal implants, deep pelvic endometriosis. The primary locations are in the pelvis; extrapelvic endometriosis may rarely occur. Diagnosis requires a combination of clinical history, invasive and non-invasive techniques. The definitive diagnosis is based on laparoscopy with histological confirmation. Diagnostic imaging is necessary for treatment planning. MRI is as a second-line technique after ultrasound. The MRI appearance of endometriotic lesions is variable and depends on the quantity and age of haemorrhage, the amount of endometrial cells, stroma, smooth muscle proliferation and fibrosis. The purpose of surgery is to achieve complete resection of all endometriotic lesions in the same operation.ConclusionOwing to the possibility to perform a complete assessment of all pelvic compartments at one time, MRI represents the best imaging technique for preoperative staging of endometriosis, in order to choose the more appropriate surgical approach and to plan a multidisciplinary team work.Teaching Points• Endometriosis includes ovarian endometriomas, peritoneal implants and deep pelvic endometriosis.• MRI is a second-line imaging technique after US.• Deep pelvic endometriosis is associated with chronic pelvic pain and infertility.• Endometriosis is characterized by considerable diagnostic delay.• MRI is the best imaging technique for preoperative staging of endometriosis.

Diffusion-MR in kidney transplant recipients: is diuretic stimulation a useful diagnostic tool for improving differentiation between functioning and non-functioning kidneys?

OBJECTIVES To evaluate the effects of diuretic stimulation on Diffusion Weighted Imaging (DWI) and Diffusion Tensor Imaging (DTI) techniques in transplanted kidneys. METHODS 33 transplanted kidney recipients underwent DWI and DTI sequences before and after furosemide. Cortical and medullary Apparent Diffusion Coefficient (ADC) and Fractional Anisotropy (FA) values were calculated in transplanted kidneys. Patients were divided into two groups according to their estimated glomerular rate filtration (Group A ≥ 60 ml/min and Group B < 60 ml/min). Wilcoxon matched pairs signed rank test was applied to compare pre- and post-furosemide values. ADC and FA values were compared between the 2 groups using a Mann-Whitney U test. Receiver Operating Curves (ROC) analysis was performed to predict normal renal function. RESULTS Wilcoxon test revealed a statistically significant difference for all pre- and post- ADC and FA values in group B. For group A, a significant difference was found comparing pre- and post-medullary ADC and FA values (p = 0.0151 and p = 0.0054). In the comparison between group A and group B, cortical and medullary mean ADC values were significantly different before and after furosemide. With regard to medullary FA values, a significant difference was found between groups before and after diuretic stimulation (p respectively of 0.004 and 0.042). Comparing cortical FA mean values, no statistical difference was observed between groups before and after furosemide. The highest Area Under Curve values were reported for cortical ADC (0.878) and medullary ADC (0.863) before diuretic bolus. CONCLUSIONS In transplanted kidneys, furosemide did not improve the differentiation between normal and reduced function.

VOIDING COLOR DOPPLER US IN THE STAGING OF VESICO-URETERAL REFLUX

Purpose: The aim of this study is to assess the accuracy of US contrast agent in ultrasonographic investigation of early diagnosis and staging of vesico-ureteral reflux. Methods and Materials: One hundredtwentytwo patients suffering of pyelocaliceal dilatation,urinary tract infections and miscellaneous diseases underwent voiding color Doppler US, followed by a cystourethrographic test. The voiding color Doppler US consists in trans-catheter introduction of a contrast agent (Levovist, Schering, AG,Berlin) into the bladder and a subsequent test with the color Doppler US to show or exclude the presence of reflux. After the introduction of the US contrast agent superpubic scans of the bladder, ureters and pielo-caliceal cavity were performed in order to evaluate reflux degree. The ultrasonographic investigations were performed with the AU 5 IDEA scan (Esaote) with a 3,5MHz convex probe. Results: In 118 patients we observed a superimposibility of results between voiding color Doppler US and cystourethrographic test (4 false positives): sensitivity 100%, specificity 90%. Conclusions: According to the data obtained, voiding color Doppler US could be used as an alternative technique to the cystourethrographic test because of the lack of risks due to ionizing radiations.